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Service Authorizations

 We must give an authorization before you do any of the following:

  • Going to a doctor that does not work with our program
  • Going to the hospital.
    • You do not need approval if it is an emergency. Go right to the ER.
    • Tell you PCP within one day if you go to the ER.
  • Orthodontia (example: braces) and inpatient oral surgery

Other tests and services may need to be authorized before you get them. Check with your child’s doctor.

You do not need a referral or authorization for the following:

  • Going to your PCP
  • The first 24 chiropractic visits in a year
  • Podiatry visits for your feet (up to 5 visits per year)
  • Family planning from providers who work with our program
  • After being discharged from the hospital or ER if your child needs follow-up care to keep the illness from getting worse

Your PCP can get an authorization for services that need one. Your PCP will need to see your child’s member ID card to do this. Make sure you have your member ID card with you. Call your doctor or CMS Nurse if you have any questions.

There may be a time when your authorization is not approved. If you appeal, you may still see your doctor and receive services. If the appeal is denied you will need to pay the cost of the visit.