The CommunityCARE PCP will provide basic medical care to the member and must provide written referrals/authorizations to other medical care providers when specialty care is needed that the PCP does not provide. For most medical care, members 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 member inform the PCP when they receive any of these services so their medical record can be updated to include the treatment information.

• Chiropractic service upon KIDMED referral, ages 0-21
• Dentures for adults
• Dental services for children, ages 0-21 (billed on the ADA claim form)
• Dental services for pregnant women, ages 21-59 (billed on the ADA claim form)
• Personal Care Services for children under age 21
• Occupational Therapy, Physical Therapy and Speech Therapy provided by schools(age 3-21)or Early Intervention Centers(under age 3)
• Ophthalmologist and Optometrist services
• Family planning services
• Hemodialysis
• NOW Waiver, Elderly and Disabled Adult Waiver, Adult day Health Care Waiver and Children's Choice Waiver services
• Hospice services
• State mental health clinic services
• Mental health rehabilitation services
• WIC services (Office of Public Health WIC Clinics)
• Prenatal/Obstetrical services
• Psychiatric inpatient hospital services
• STD clinic services (Office of Public Health)
• Long Term Personal Care Services (PCS) for adults
• Services provided by School Based Health Centers to members age 10 and over
• Immunizations for children under age 21 (Office of Public Health and their affiliated providers)
• Inpatient Care that has been pre-certed (this also applies to public hospitals even though they aren't required to obtain pre-certification for inpatient stays): hospital, physician and ancillary services
• Targeted case management
• Transportation services
• Tuberculosis clinic services (Office of Public Health)
• Pharmacy
• Psychiatrist services
• Inpatient Psychiatric services (distinct part and freestanding psychiatric hospital)
• The three higher level (CPT 99283, 99284, 99285) emergency room visits and associated physician services (NOTE: The two lower level Emergency room visits (CPT 99281, 99282) and associated physician services do not require prior authorization, but do require POST authorization.) Refer to "Emergency Services" in the CommunityCARE Handbook.
• Specific outpatient laboratory/radiology services
• Children's Special Health Services provided by OPH

CommunityCARE members seeking non-exempt medical services (any service not listed above) from a provider who is not listed as the CommunityCARE PCP on the member’s Medicaid file (MEVS/REVS/eMEVS) should be instructed to call their PCP or a CommunityCARE Service Representative at 800.259.4444.

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 member’s medical record.

• The member’s name and 13-digit Medicaid number
• The name of the provider to whom the member 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.

Note: This information is not inclusive of the CommunityCARE referral guidelines. Please refer to the CommunityCARE Provider Handbook.