Answers to Frequently Asked Questions about Personal Choice/AHC

• Referrals do not override contract benefits.
• Referrals and precertifications are mutually exclusive of each other. It is possible that a patient not need a referral and need precertification. A predetermination may be obtained from Medical Review for certain proposed treatment plans.

1. Referral – from PCP to specialist or facility
2. Precertification – determines appropriateness of location of treatment
3. Predetermination – determines medical necessity of proposed treatment plan

• Retro-referrals can be obtained only in the case of PCP office error.
  (Specific protocol must be followed.)
• Physical therapy, speech therapy, DME and home health (participating agencies only)
  do not require a referral when ordered by the PCP or specialist with a current referral.
• Chiropractors and podiatrists require referrals.
  (Use Participating Chiropractors only.)
• Dentists do not require a referral unless the services are TMJ related or
  accident related.
• All OB services require a referral, even if the patient is already pregnant when they change insurance to Personal Choice or AHC.
• If PCN is secondary insurance, referrals are still required except when Uniroyal Medicare is primary.
• All referrals must be reissued if the patient has changed their PCP. The PCP may be changed twice a year, even if the new PCP is in the same office.
• A separate referral from the PCP is required if the “referred to” specialist sends the patient to another physician.
• All emergency room (ER) visits require a referral. The PCP determines the medical necessity of the ER visit prior to issuing the referral. If the member is admitted through admissions, a referral is not required. Use the PCP’s Unique Provider Identification Number (UPIN) if admitting or the referral must be on file for the specialist admitting the patient through the admitting department.
• Referrals are required for neonatologists.
• Referrals are required for anesthesiologists for epidurals used in pain management