Prior Authorization
The CommunityCARE PCP will provide basic medical care to the enrollee and must provide written referral/authorizations to other medical care providers when specialty care is needed that the PCP does not provide. For most medical care, enrollees must contact their CommunityCARE PCP before going to another physician, clinic or hospital.

The services listed below are considered exempt services and do not require the PCP to issue a referral/authorization. However, it is recommended that the CommunityCARE enrollee inform the PCP when they receive any of these services so their medical record can be updated to include the treatment information.

A list of exempt services that DO NOT require a PCP referral:
• Chiropractic services from KIDMED referral
• Dentures for adults
• Family planning services
• Dental services for children
• Optometrist and ophthalmologist services
• Psychiatrist services
• Emergency and non-emergency transportation
• Pharmacy services
• Nursing home services
• Home and community-based waiver services
• Case management services
• Prenatal/obstetrical care
• Hemodialysis
• EPSDT health services provided by schools or Early Intervention Centers for special-needs children
Note: A referral is required for Children’s Special Health Services clinics
(Handicapped Children’s Services) operated by the Office of Public Health.
• OPH tuberculosis clinic services
• OPH sexually transmitted disease clinic services
• Inpatient hospital care that has a pre-certification number on file (physician and hospital)
• Mental health clinic services
• Mental health rehabilitation services
• Neonatal/pediatric subspecialty care for inpatient newborns
• Inpatient psychiatric services (free-standing and distinct part)
• Emergency services - the three highest level emergency room visits (the two lowest level emergency room visits require post authorization from the PCP)

CommunityCARE enrollees seeking non-exempt medical services (any service not listed above) from a provider who is not listed as the CommunityCARE PCP on the recipient’s Medicaid file (MEVS/REVS) should be instructed to call their PCP or a CommunityCARE Service Representative at 1-800-359-2122.

Referral Form
A written, signed referral/authorization is required. Signature stamps or computer-generated signatures are acceptable, but MUST BE initialed by the provider or the authorized representative. If an original signature, or signature stamp or computer-generated signature is not initialed, the referral IS NOT valid.

An electronic referral/authorization process is available to hospitals and PCPs for emergency services. To obtain information regarding that process, providers should contact their Unisys Provider Relations representative.

PCPs can use the CommunityCARE referral form or any other format as long as it contains all the required information. The PCP must keep a copy of the signed, written referral in the enrollee’s medical record.

Required Referral Information:
• The enrollee’s name and 13-digit Medicaid number
• The name of the provider to whom the enrollee is being referred
• The purpose of the referral
• The diagnosis or suspected condition
• The PCP’s seven-digit Medicaid provider number on the referral (this serves as the authorization number)
• All expectations, limitations, and restrictions (including length of treatment or number of treatments) the PCP is placing on the use of the referral.

A referral cannot exceed a 6-month period. If specialist care is still necessary after 6 months, a new referral is required. An exception to the 6-month limitation is in certain medically high risk circumstances as detailed in the CommunityCARE Handbook.

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