Referrals and prior authorizations in DC
For some DC Medicaid services, you’ll need a referral from your primary care provider (PCP) before getting care.
When to get a referral
A referral is when your PCP sends you to another provider for care. You’ll need to get a referral from your PCP before:
- Meeting with a specialist.
- Going to a hospital for nonemergency care.
- Getting certain medicines, tests, and services.
You don’t need a referral from your PCP for:
- Emergency care
- Well-woman checkups
- Family planning
- Immunizations (shots)
- Care services for mental health, alcohol, or substance abuse from a provider in the network
You may need prior authorization for a service
A prior authorization is when your doctor asks us to approve a service before you receive it. Your PCP will work with us to get the prior authorizations you need.
Your PCP will need to send prior authorization for:
- Most surgeries, including some outpatient surgeries
- All elective and nonurgent inpatient services and admissions
- Certain prescriptions
- Certain durable medical equipment, including prosthetics and orthotics
- Hearing aids
- Home health services
- Hospice services
- Rehabilitation therapy (physical, occupational, respiratory and speech therapies)
- Sleep studies
- Out-of-area or out-of-network care except in an emergency and for family planning
- Advanced imaging (things like MRAs, MRIs, CT scans and CTA scans)
Have questions?
Check your enrollee handbook or live chat with a representative through the online portal or the SydneySM Health mobile app.
This program is brought to you by the Government of the District of Columbia Department of Health Care Finance.