Go directly to: Content
NOTICE: You are using a browser without adequate or enabled CSS (style sheet) support.
This site will appear plain but remain fully useable. To see this site as it is intended, you need to
upgrade to a standards-compliant browser, such as the latest version of
Internet Explorer or
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.
- Referral – from PCP to specialist or facility
- Precertification – determines appropriateness of location of treatment
- Predetermination – determines medical necessity of proposed treatment
- 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
do not require a referral when ordered by the PCP or specialist with a current
- Chiropractors and podiatrists require referrals.
(Use Participating Chiropractors only.)
- Dentists do not require a referral unless the services are TMJ 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