Referrals and Authorizations

Referrals

We do not require a referral from your PCP in order to see a specialist. However, some specialists may require a referral. If that is the case, they will tell you.

For some medical services, you may need a referral from your PCP. If you need one of these services, your PCP will coordinate your care and refer you to a provider. If you would like help finding an in-network provider, please call Member Services and we’ll be happy to help.

The following are services requiring a referral from your PCP:

Diagnostic tests (X-ray & lab)
Scheduled outpatient hospital services
Planned Inpatient admission
Clinic services
Renal dialysis (kidney disease)
Out-of-network providers require Louisiana Healthcare Connections approval
Durable Medical Equipment (DME)
Home health care

Prior Authorization for Services

When you need care, always start with a call to your doctor. Some covered services may require Prior Authorization by Louisiana Healthcare Connections. Prior Authorization means approval needed before a service is provided or approval needed to continue a service.

Services Requiring Prior Authorization

Your provider can tell you if a service needs Prior Authorization. You can also call Member Services at 1-866-595-8133 (TTY: 711) to see if something needs Prior Authorization.

In most cases, the following services must be approved before you get them:

Advanced radiology
Durable Medical Equipment (DME) rentals and purchases
Elective inpatient procedures
Genetic testing
Home health services
Inpatient admissions
Inpatient rehabilitation facility admissions
Long-term acute care hospital admissions
Outpatient therapy services
Pain management services
Pharmacy injectables
Select outpatient procedures
Skilled nursing facility admissions
Home location services

A Prior Authorization decides if a service should be covered based on:

whether the service is needed (medical necessity)
whether the service is likely to be helpful (clinical appropriateness)

Your provider will give us information (over the phone or in writing) about why you need the service. We will look to see if the service is covered and ensure it is medically necessary. We will make the decision as soon as possible based on your medical condition. Decisions are usually made within 14 calendar days. If you need to be admitted to the hospital for an urgent medical need, the decision will be made within two calendar days. If you require ongoing inpatient care, the decision will be made within one calendar day.

We will let your provider know if the service is approved or denied. If you or your provider are not happy with the decision, you can request a second review. This is called an Appeal. See the Member Satisfaction section of your Member Handbook for more information.

NOTE: Emergency Room (ER) and post stabilization services NEVER require Prior Authorization. If there are any major changes to the Prior Authorization process, we will inform our members and providers right away.

Prior Authorization for Medications

Some medications may require Prior Authorization by Prime Therapeutics State Government Solutions (Prime Therapeutics), Louisiana Medicaid’s Pharmacy Benefits Manager, before they are covered by your health plan. Prime Therapeutics handles Prior Authorizations for all Louisiana Medicaid health plans. Your provider can tell you if a medication needs Prior Authorization. You can also call Prime Therapeutics' 24/7 Member Help Desk at 1-800-424-1664 (TTY: 711) to see if a medication needs Prior Authorization.

If Prior Authorization is needed, your provider will give Prime Therapeutics information about why you need the medication. Prime Therapeutics will base its decision on the Louisiana Medicaid Single PDL and the information provided by your doctor. Prime Therapeutics will let your provider know if the medication is approved or denied.

If you or your provider are not happy with the decision, you can request a second review from Louisiana Healthcare Connections. This is called an appeal.