Referrals and Prior Authorizations
Referrals
A referral is when your primary care provider (PCP) sends you to another provider for care.
You will need a referral before getting these services:
- Seeing a specialist
- Going to a hospital for nonemergency
- Getting certain medicines, tests, and services
You do not need a referral before getting these services:
- Visits to your PCP
- Emergency care
- Well-woman checkups
- Family planning
- Immunization (shots)
- Care services for mental health, alcohol, or substance abuse from a provider in the network
Prior Authorizations
You may need a prior authorization from us before getting certain care. Your primary care provider will work with us to get the authorization that you need.
Prior Authorization process:
Your primary care provider or other healthcare provider must give Amerigroup DC information to show that the service or medication requested is medically necessary.
Medical Necessity is defined as: Services that promote normal growth and development and prevent, diagnose, detect, treat, improve the effects or a physical, mental, behavioral, genetic, or congenital condition, injury, or disability and in accordance with generally accepted standards of medical practice, including clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the Enrollee’s illness, injury, disease, or physical or mental health condition.
Amerigroup DC nurses or pharmacists review the information provided. The nurse or pharmacists will use clinical guidelines approved by the Department of Human Services to see if the service or medicine is medically necessary.
If the request cannot be approved by an Amerigroup DC nurse or pharmacist, an Amerigroup DC doctor will review the request
If the request is approved, we will let you and your healthcare provider know the request was approved
If the request is not approved, a letter will be sent with the reason for the decision
If you disagree with the decision, you may file a complaint or grievance and/or request a fair hearing
You may also call Enrollee Services for help in filing a complaint or grievance, or requesting a fair hearing
Authorization Decision Timelines
Non-Urgent Standard Authorization:
- 3 business days of receiving request via electronic portal
- 5 business days of receiving request via phone or mail or fax
Urgent Authorization:
- 24 hours
You can find more about your benefits in your enrollee handbook. If you have questions or would like a copy of your handbook mailed to you, call Enrollee Services at 800-600-4441 (TTY 711).
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Enrollee Services 800-600-4441 (TTY 711)