How to Get Specialty Care – Referrals
A specialist is a doctor who provides health care services for a specific disease or a specific part of the body. When your PCP thinks that you need a specialist, he or she will refer you (or handoff your care) to a network specialist. There are many kinds of specialists. Here are a few examples:
- Oncologists care for patients with cancer.
- Cardiologists care for patients with heart conditions.
- Orthopedists care for patients with certain bone, joint or muscle conditions.
When your PCP thinks that you need specialized treatment, he or she will give you a referral (approval in advance) to see a network specialist or certain other providers.
To find providers in our network, use our online provider directory, or contact Member Services, 24 hours a day, seven days a week: 1‑833‑704‑1177 (TTY 1‑855‑534‑6730).
For some types of referrals, your PCP may need to get approval in advance from our plan. This is called getting “prior authorization”. Prior Authorization is a request for services that are submitted by your PCP/Provider with clinical information to help make a decision about the service. The information will be reviewed by AmeriHealth Caritas New Hampshire’s Utilization Management (UM) team against criteria for medical necessity.
It is very important to get approval in advance from your PCP before you see a network specialist or certain other providers.
If your PCP refers you to another doctor, we will pay for your care. Most of these specialists are AmeriHealth Caritas New Hampshire providers. Talk with your PCP to be sure you know how referrals work.
- 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 New Hampshire 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 1‑833‑704‑1177 (TTY 1-855-534-6730). Please call Member Services for more information on how to receive dental and vision services.
If you have a complex health condition or a special health care 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 1‑833‑704‑1177 (TTY 1‑855‑534‑6730). We will work with you to help coordinate the care that you need.
Getting care from out-of-network providers
If AmeriHealth Caritas New Hampshire 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 New Hampshire 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 1‑833‑704‑1177 (TTY 1‑855‑534‑6730) to discuss your needs and to get more details. We will review and make a decision about your request.
- Sometimes we may not approve an out-of-network referral because we have a provider in the AmeriHealth Caritas New Hampshire network 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 New Hampshire provider. If you do not agree with our decision, you can appeal our decision.
If you are an American Indian or Alaska Native (AI/AN) of a federally recognized tribe or another individual determined eligible for Indian health care services, special coverage rules apply. You may get out-of-network services at an Indian health facility without prior authorization. Contact Member Services for more information at 1‑833‑704‑1177 (TTY 1‑855‑534‑6730).
When you receive prior authorization from the plan for treatment from an out-of-network provider, you should never be charged more than a prescription drug copayment, if any, for covered services. If you are charged for covered services, please contact Member Services at 1‑833‑704‑1177 (TTY 1‑855‑534‑6730).
Get these services without a referral
You can get the services listed below without getting approval in advance from your PCP or AmeriHealth Caritas New Hampshire.
- Routine women’s health care, including breast exams, screening mammograms (X-rays of the breast), pap tests, pelvic exams, and maternity care.
- Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations, as long as you get them from a network provider.
- Emergency services from network providers or from out-of-network providers.
- Urgently needed services from network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible (e.g., when you are temporarily outside of the plan’s service area).
- Family planning services when you go to any participating New Hampshire Medicaid family planning provider.
- 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.
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 1-855-375-8811 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.
What happens when a network provider leaves our plan
We may make changes to the hospitals, doctors, and specialists (providers) that are part of our plan during the year. Also, sometimes your provider might leave the network. If your doctor or specialist leaves our plan, learn more about your rights and protections.