Prior Authorization/Referral

How to Get Covered Services

Call your PCP when you need regular care. He or she will send you to see a specialist for tests, specialty care and other covered services that he or she doesn’t provide. Be sure your PCP approves you to see a specialist. If your PCP does not provide an approved service, ask him or her how you can get it.

Understanding Referrals and Prior Authorizations


You may see any doctor in our network without a referral. However, some doctors may request a referral from your PCP. We will still cover medically necessary services provided by an in-network provider without a referral.

You may be referred to another provider if:

  • Your PCP does not provide the care or service you need
  • You need to see a specialist

You could be referred for medical tests, treatments or other services.

Referrals for certain care or services do not require our approval. These include:

  • Routine diagnostic tests
  • Lab tests
  • Basic X-ray services
  • Some routine care provided in a doctor’s office (not in a hospital)

Prior Authorizations (PAs)

Sometimes, your PCP or another provider may need to ask us to approve care before you get a service. This is called prior authorization (or PA for short). Your PCP or provider will contact us for this approval.

A PA is needed for these types of services:

  • Rented or purchased medical supplies and equipment that costs more than $250
  • Some medical tests done by your PCP or provider
  • Cardiac and pulmonary rehabilitation programs
  • Home health care
  • Therapies (physical, occupational, speech)
  • Inpatient and residential behavioral health services

This is not a complete list, and it may change from time to time. See your member handbook for a current list of services that require a PA.

If we do not approve a PA request, we’ll let you know. If we do not approve a PA request, and you still receive the service, the provider cannot bill you unless you agreed to pay for it in writing. If a PA is denied, you can ask for an appeal. If you still are not happy once the appeal is complete, you can ask for a State Fair Hearing. See your member handbook for more information.

Prior Authorization "How-To"

Type of Request Decision Time Frame Who Can Request One

Type of Request

Decision Time Frame

Who Can Request One

Standard (for non-emergency care)

2 business days*

Your provider

Expedited/Fast** (for urgent care)

24 hours**

Your provider

*Sometimes we may need more time to make a standard decision. This may be because we need more information and it’s in your best interest. If so, we’ll take up to 14 more business days.

**Sometimes we may need more time to make a fast decision. If so, we’ll take up to 48 more hours.

Please note: PA decisions for services that have already been provided are made within 30 calendar days of us getting all needed information.

Services Available Without Authorization

You don’t need approval from us or your PCP for the following services:

  • Direct access to in-network women’s health specialists for routine and preventive health care services
  • Emergency/urgent care
  • Family planning (any health plan provider)*
  • Well-child visits for children age 20 or younger
  • Routine vision care
  • One women’s health visit to an OB/GYN provider each year
  • Post-stabilization services
  • Visits to your PCP
  • Most outpatient behavioral health services (in-network)

Even though you don’t need approval for these services, you will need to see a provider in our network.

*Information about your family planning services will be kept private and, unless required by law, will not be shared with anyone without your approval, even if you are under the age of 18.

You can find a provider using our online provider search tool – Find a Provider. When you’ve made your choice, call to set up an appointment. Remember to take your ID cards with you.

Prior Authorizations
Services that Require a Prior Authorization Prior Authorization Required for Some or All of the Services?
Advanced Radiology Services (CT, CTA, MRA, MRI, Nuclear Cardiology, Nuclear Medicine, PET & SPECT Scan) Yes
Ambulatory Surgery Center Some items require prior authorization
Bariatric Surgery (Certain restrictions and limitations may apply) Yes
Cardiology Services (Cardiac Imaging, Cardiac Catheterization, Diagnostic Cardiac Procedures and Echo Stress Tests) Yes
Dialysis No
Durable Medical Equipment (DME) Some items require prior authorization
Elective Inpatient Services Yes
Emergency Services (Ambulance, Behavioral Health Services, Emergency Room Services, and Urgent Care Services) No
Home Health Care Services Yes
Hospice Admissions Yes
Hospice Care Services No
Hospital Services Inpatient Yes
Hospital Services Outpatient Some services require prior authorization
Investigational and Experimental Procedures and Treatment Yes
Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. Yes- Some services require prior authorization
Long-Term Acute Care Hospital (LTACH) Yes
Medical Oncology Services Yes
Neonatal intensive care unit (NICU)/Sick Baby Admissions Yes
Obstetric Global Care Yes
Orthopedic Surgery No
Orthotics & Prosthetics (O&P): Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. Yes
Out of Network Provider Services Yes
Outpatient Services Yes
Oxygen & Respiratory Services Some services require prior authorization
Pain Management Yes
Prescribed Pediatric Extended Care Yes
Radiation Therapy Management Yes
Select Outpatient Procedures Yes
Skilled Nursing Facility Admissions Yes
Sleep Diagnostics Yes
Spinal Therapy and/or Surgery Yes
Sterilization Services No
Substance Use Disorder Services Some services require prior authorization

Termination of Pregnancy

Therapy (OT, PT, ST) Services (Outpatient and including home based therapy) Yes
Transplant Services Yes

All such services determined by Kentucky Medicaid to be medically necessary shall constitute a WellCare of Kentucky Covered Service. See the WellCare of Kentucky Member Handbook for more information on coverage out-of-network and out of the WellCare of Kentucky service area.

Documents and Resources

Notification of Pregnancy (PDF)

Do I need a referral to see a specialist?

No, you do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, chiropractic services, or mental health/counseling services.

Drug Approval Criteria