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Referrals

Notification to AmeriHealth Caritas District of Columbia is requested when a primary care provider (PCP) refers a member to a participating specialist. Referrals are valid for 180 days with unlimited visits.

How to submit a referral

Electronically

To submit an electronic referral:

  • Log in to NaviNet. If your office is not currently using NaviNet, you may enroll online at www.navinet.net by selecting Sign Up or via telephone by contacting NaviNet customer service at 1-888-482-8057.
  • Once you log in to NaviNet, select Referral Submission or Referral Inquiry and follow the steps to refer a member or view referrals.
  • For more specific instructions, refer to the user referral materials available under Customer Service on the NaviNet website.

On paper

Referral forms may be requested by contacting Provider Services at 1-202-408-2237 or 1-888-656-2383 or your provider account executive. You may also use the referral supply request form (PDF) to fax in your request.

To submit a paper referral:

  • Complete all requested fields on the referral form and ensure that the form is legible.
  • Ensure the date of service is not prior to the date of the referral.
  • Mail a copy of the referral to the address provided on the Referral Form.
  • Please give a copy of the Referral form to the member to present upon visiting the consulting specialist/hospital or other outpatient facility.

Services that require referrals

  • Allergy testing/injections/serum
  • Diagnostic procedures performed by a specialist in an office setting
  • Dialysis-associated physician services for members without Medicare coverage
  • Diabetic counseling
  • EPSDT-related dental services for children three years of age and older
  • Fracture care
  • Injectables administered during a specialist office visit
  • Nutritional counseling
  • Medically-necessary oral surgery
  • Outpatient diagnostic X-rays
  • Second and third opinions
  • Sleep studies conducted in a specialist office
  • Visits to a specialist, hospital or other outpatient facility
    (except for the direct access services listed below)

Direct access services that do not require referrals

  • Emergency services
  • Immunizations
  • Prenatal OB visits
  • Routine OB/GYN visits and women's preventative healthcare services
  • Routine family planning services
  • Services for sexually transmitted diseases (STDs)
  • Routine dental services

Additionally, AmeriHealth Caritas District of Columbia Medicaid members have direct access to:

  • Routine vision services
  • Initial 10 sessions of outpatient behavioral health counseling and therapy (individual, family, group)