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Answers to Frequently Asked Questions
about the Personal Choice Network
- Referrals do not override contract benefits.
- Referrals and precertifications are mutually exclusive of each other. It
is possible that a patient does not need a referral
but needs a 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 a PCP office error.
(Specific protocol must be followed.)
- Physical therapy, speech therapy, durable medical equipment 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 Network Providers only.)
- Dentists do not require a referral unless the services are temporomandibular joint (TMJ) related
- If a member's Personal Choice plan is secondary insurance, referrals are still required.
- 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 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 National Provider Identifier (NPI) if admitting or
the referral must be on file for the specialist admitting the patient through
the admitting department.