How to Get Specialty Care
If you need specialized care that your primary care provider (PCP) cannot give, your PCP will refer you to a specialist who likely can. A specialist is a doctor who is trained and practices in a specific area of medicine (like a cardiologist or a surgeon). Many specialists are AmeriHealth Caritas Ohio providers.
AmeriHealth Caritas Ohio does not require referrals to in-network specialists. Prior authorization is required for out-of-network providers.
If you think a specialist does not meet your needs, talk with your PCP. Your PCP can help you if you need to see a different specialist.
There are some treatments and services that your PCP must ask AmeriHealth Caritas Ohio to approve before you can get them. Your PCP will be able to tell you what they are.
If you have trouble getting a referral you think you need, contact Member Services at 1-833-764-7700 (TTY 1-833-889-6446).
If AmeriHealth Caritas Ohio does not have a specialist in our provider network who can give you the care you need, we will refer you to a specialist outside our plan. This is called an out-of-network referral.
Your PCP or another network provider must ask AmeriHealth Caritas Ohio for approval before you can get an out-of-network referral. You can talk to your PCP about this or call AmeriHealth Caritas Member Services at 1-833-764-7700 (TTY 1-833-889-6446), to discuss your needs and to get more details. We will review and make a decision about your request within 14 days for a standard request and three days for an expedited request.
Sometimes we may not approve an out-of-network referral because we have a provider in AmeriHealth Caritas Ohio who can treat you. If you do not agree with our decision, you can appeal our decision.
Sometimes, we may not approve an out-of-network referral for a specific treatment because you asked for care that is not very different from what you can get from an AmeriHealth Caritas Ohio provider. If you do not agree with our decision, you can appeal our decision.
If you have a complex health condition or a special healthcare need, you may be able to choose a specialist to act as your PCP. For more information or to request to choose a specialist as your PCP, call Member Services at 1-833-764-7700 (TTY 1-833-889-6446). We will work with you to help coordinate the care that you need.
Get these services from AmeriHealth Caritas Ohio without a referral
You do not need a referral to get primary care services. If you need a checkup or have a question about your health, call your PCP to make an appointment.
You do not need a referral from your PCP if:
- You are pregnant and need pregnancy-related services.
- You need OB/GYN services.
- You need family planning services.
- You need to have a breast or pelvic exam.
You can go to any health provider or clinic that takes Medicaid and offers family planning services. You can also visit one of our family planning providers. Either way, you do not need a referral from your PCP. You can get birth control and birth control devices (IUDs, implantable contraceptive devices, and others) that are available with a prescription, and emergency contraception and sterilization services.
You can also see a family planning provider for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing, treatment, and counseling related to your test results. Screenings for cancer and other related conditions are also included in family planning visits.
Children’s screening and local health department services
You do not need a referral to get children’s screening services, school-based services or services from your local health department.
Behavioral health services
You do not need a referral for your first behavioral health or substance use disorder assessment completed in a 12-month period. Ask your PCP or call Member Services at 1-833-764-7700 (TTY 1-833-889-6446), for a list of mental health providers (who serve adults and children) and substance use disorder providers. You can also find a list of our mental health and substance use disorder providers online in our provider directory.