what is self referral and what are the covered service under self referral?

Self-Referral Services

Self-referral services are defined in the HealthChoice regulations as “health care services for which under specified circumstances the MCO is required to pay without any requirement of referral or authorization by the primary care provider (PCP) or MCO when the enrollee accesses the services through a provider other than the enrollee’s PCP.”

The following services must be reimbursed by the MCO without a referral:

Child With Pre-Existing Medical Condition - Medical Services

Child In State-Supervised Care - Initial Medical Exam

 Emergency Services Family Planning Services

HIV/AIDS Annual Diagnostic and Evaluation Service Visit

Newborn’s Initial Medical Examination In A Hospital

Pregnancy-Related Services Initiated Prior To MCO Enrollment

Renal Dialysis Services Provided In A Medicare Certified Facility

School-Based Health Center Services Substance Abuse Assessment

For additional information regarding the above self-referral services contact the Division of Outreach Care and Coordination at 410-767-6750/6859.

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