Referrals and preapprovals for Wellpoint

For some NJ FamilyCare/Medicaid services, you’ll need a referral from your primary care provider (PCP) before getting care.

When to get a referral

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.

For most services, you'll go to your PCP or another provider in our plan. But there are some services we'll pay for, even if you get them from a provider who's not in our plan. These are called self-referral services.

You don’t need a referral from your PCP for:

Emergency care
In-network specialists
Family planning services
Yearly OB/GYN exams and prenatal care
Dental care from a LIBERTY Dental plan dentist
Vision care from a Superior Vision plan provider
Sexually transmitted disease (STD) testing
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services
Certain providers for children with special healthcare needs

Your PCP will need to send in a preapproval for:

Most surgeries, including some outpatient surgeries
All elective and routine inpatient services and admissions
Advanced imaging (MRAs, MRIs, CT, CTA scans)
Experimental and investigational treatments
Chiropractic services
Most behavioral health and substance abuse services, including psychological testing (except routine outpatient and emergency services)
Certain medicines and durable medical equipment (DME), including prosthetics and orthotics
Gastroenterology procedures, including upper endoscopy and bariatric surgery
Digital hearing aids
Home health and hospice services
Rehabilitation therapy (physical, occupational, respiratory, and speech)
Sleep studies
Managed long‐term services and supports
Out‐of‐area or out‐of‐plan care, except in cases of emergency
Some pain management testing and procedures