Referrals and prior authorizations
Before you get certain services, you may need a referral or prior authorization. To get a referral or prior authorization, talk to your primary care provider (PCP).
Your PCP may send you to a specialist for care. This is called a referral. Your PCP will set up the appointment with the specialist for you.
If the specialist is not in our plan, your PCP must get an OK from us first. If you have copays, your copay is the same even if the specialist is not in our plan.
You cannot go to a specialist without your PCP’s referral. We will only pay for a specialist visit if your PCP sends you.
You do not need a referral from your PCP for these services:
- Well-woman checkups or prenatal care from a women’s health doctor (OB/GYN) in our plan
- Behavioral health care for mental health, alcohol or substance abuse services from a provider in our plan
- Emergency care
- TennCare Kids screenings
Some kinds of care need an OK from Amerigroup before TennCare will pay for it. This is called a prior authorization.
- Planned inpatient admissions
- Certain behavioral health services
- Certain prescriptions
- Rehabilitation therapies
- Home health services
- Pain management
As a member, you don't make the prior authorization request. Your PCP or other provider should send in the request. If we cannot OK the request, we'll send you a letter telling you why.
Call us at 1-800-600-4441 (TTY 711). Additional benefit details are also available in your member handbook.