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.