In-Network Referrals
Primary care providers (PCPs) can refer a member to an in-network specialist for consultation and treatment without a prior authorization request to PCHP.
Out-of-Network Referrals
If the PCP believes that a member needs to be referred to an out-of-network provider, including medical partners not contracted with PCHP, documentation demonstrating the need must be submitted to PCHP for review and prior authorization before the referral can occur.
There must be documentation of coordination of referrals and services provided between the PCP and specialist.
Routine specialist care referrals must be provided within 30 calendar days of the referral.
Members may access behavioral health benefits by contacting providers directly. No primary care referrals are needed.
Members may access routine vision services without a referral from their PCP, provided they are coordinated through Avesis.
Requesting a referral can be done on the PCHP Provider Portal.