What is an out-of-network referral?
If you need care that your primary care provider (PCP) cannot provide, you can go to a specialist without a referral from your PCP. A specialist is a doctor trained in a specific area of medicine such as cardiology or surgery.
If we do not have a specialist in our provider network who can give you the care you need, we will refer you to a specialist outside of our health plan network. This is called an “out-of-network referral”. Your PCP or another network provider must ask us for approval before we will pay for you to go an out-of-network provider
An out-of-network referral is different than prior approval. To learn more about prior approvals, visit the “Prior approvals” section below.
Prior approvals (an OK from Anthem)
What is prior approval?
There are some treatments and services your PCP must ask us to approve before we will pay for you to receive them. This is called “prior approval.” We will review your PCP’s request to determine if the service is medically needed and if it is included in your Anthem Medicaid benefits.
If your prior approval request is denied, you or your PCP can ask us to take another look. This is called an “appeal.” Appeals ask for a second review of the care or services requested and denied or those that have been limited in the amount or length of time from what was requested.
Here are a few examples of services that do not require prior approval.
- Emergency care
- Family planning
- Visits to urgent care centers
Here are a few examples of services that do require prior approval.
- All out-of-network services
- Brand-name drugs, if there is an approved generic version in your plan’s formulary
- Computed axial tomography (CAT) scans
- Echocardiogram (Echo)
- Magnetic resonance angiography (MRA)
- Magnetic resonance imaging (MRI)
- Nuclear heart scan
- Prescriptions with quantities more than a standard 30-day supply or with multiple doses (MedImpact)
How we make decisions on care and services
We often need to make decisions about how we pay for care and services. This is called utilization management (UM). Our UM program looks at what, when, and how much of our services are medically needed. We always strive for the best possible health outcomes for our members.
Our UM program does not tell providers to withhold or give you fewer services. We also do not reward them for limiting or denying care. Healthcare providers may reference our Medical Policies and Clinical UM Guidelines for guidance. You can access the Kentucky Medicaid Medical Policies and Clinical UM Guidelines here. You will need to enter your name and email address to receive an access code.
If you have questions about an approval or a denial you received, you can call Member Services at 855-690-7784 (TTY 711) from 7 a.m. to 7 p.m. Eastern time, Monday through Friday, except holidays.”
We want to hear from you
Every year, we survey our members about the benefits we offer. You may receive a survey by mail, email, or phone. We ask that you please complete it. Your feedback helps us make your plan better.