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Specialists, Prior Authorizations, and Referrals

A specialist is a doctor who has extra training and is an expert on certain health conditions or parts of the body. Your primary care provider (PCP) will know when you need to see a specialist and advise you on what type of specialist you need.

If you have chronic back pain, your PCP might send you to an orthopedist. For heart issues, you might see a cardiologist.

You don't need a referral to see a specialist. For some services, such as surgery or a hospital stay, you still need approval before you can get them. This is to make sure that the care is medically needed and right for you.

Services that require prior authorization:

  • All inpatient hospital admissions (including medical, surgical and rehabilitation)
  • All out-of-network services (except emergency services)
  • Cardiac services
  • Elective or non-emergent air ambulance transportation
  • Elective transfers (for inpatient and/or outpatient services between acute care facilities)
  • Enteral feedings (including related durable medical equipment [DME])
  • Home-based services
  • Home health care (after 12 visits for therapies and 6 visits for skilled nurse visits)
  • Home infusions and injections ($250 and over) provided in an outpatient setting; not required for outpatient hospital setting
  • Inpatient medical detoxification
  • Inpatient services
  • Long-term care (initial placement if still enrolled with the plan)
  • Obstetrical admissions and newborn deliveries (exceeding 48 hours after vaginal delivery and 96 hours after cesarean section)
  • Private duty nursing and extended home health services (when covered)
  • Speech therapy, occupational therapy, and physical therapy (after 12 visits for each modality)
  • Therapy and related services

Services that do not require prior authorization:

  • Diagnosis and treatment of sexually transmitted diseases (STDs) and other communicable diseases, such as tuberculosis and HIV, rendered by the DC Health Department
  • Imaging procedures related to emergency room services, observation care, and inpatient care
  • Immunizations by the DC Health Department and participating PCPs
  • OB/GYN services for 1 annual visit and the medically necessary follow-up care for a condition detected at that visit (the member must use a plan provider for these services)
  • Podiatry and some dermatology services (the member must see a plan provider for these services)
  • Routine and preventive women's health care services provided by a specialist

Services that require notification:

  • Maternity obstetrical services (after the 1st visit) and outpatient care (includes 30-hour observations). Prenatal care providers are expected to complete the D.C. Collaborative perinatal risk screening tool (PDF) to assess risk for each expectant mother. The completed screening tool must be submitted to AmeriHealth Caritas District of Columbia via fax at 1-888-603-5526 as part of the authorization for obstetric services.
  • Normal newborn deliveries