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How to Get Specialty Care

If you need specialized care that your primary care provider (PCP) cannot give, your PCP will refer you to a specialist who likely can. A specialist is a doctor who is trained and practices in a specific area of medicine (like a cardiologist or a surgeon). Many specialists are AmeriHealth Caritas North Carolina providers. Talk with your PCP to be sure you know how referrals work. See below for the process on referrals to a specialist who is not in our provider network.

If you think a specialist does not meet your needs, talk with your PCP. Your PCP can help you find a different specialist.

There are some treatments and services that your PCP must ask AmeriHealth Caritas North Carolina to approve before you can get them. Your PCP will tell you what they are.

If you have trouble getting a referral you think you need, contact Member Services at 1-855-375-8811 (TTY 1-866-209-6421).

If AmeriHealth Caritas North Carolina does not have a specialist in our provider network who can give you the care you need, we will refer you to a specialist outside our plan. This is called an out-of-network referral. Your PCP or another network provider must ask AmeriHealth Caritas North Carolina for approval before you can get an out-of-network referral.

You can talk to your PCP about this or call AmeriHealth Caritas Member Services at 1-855-375-8811 (TTY 1-866-209-6421) to discuss your needs and to get more details. We will review and make a decision about your request within 14 days for a standard request and three days for an expedited request.

Sometimes we may not approve an out-of-network referral because we have a provider in AmeriHealth Caritas North Carolina who can treat you. If you do not agree with our decision, you can appeal our decision.

Sometimes, we may not approve an out-of-network referral for a specific treatment because you asked for care that is similar to what you can get from an AmeriHealth Caritas North Carolina provider. If you do not agree with our decision, you can appeal our decision.

If you have a complex health condition or a special health care need, you may be able to choose a specialist to act as your PCP. For more information or to request to choose a specialist as your PCP, call Member Services at 1-855-375-8811 (TTY 1-866-209-6421). We will work with you to help coordinate the care that you need.

Out-of-network providers

If we do not have a specialist in our provider network who can give you the care you need, we will get you the care you need from a specialist outside our plan, or an out-of-network provider. For help and more information about getting services from an out-of-network provider, talk to your PCP or call Member Services at 1-855-375-8811 (TTY 1-866-209-6421).

Get these services from AmeriHealth Caritas North Carolina without a referral

Primary care

You do not need a referral to get primary care services. If you need a checkup or have a question about your health, call your PCP to make an appointment.

Women's health care

You do not need a referral from your PCP if:

  • You are pregnant and need pregnancy-related services
  • You need OB/GYN services
  • You need family planning services
  • You need to have a breast or pelvic exam

Family planning

You can go to any health provider or clinic that takes Medicaid and offers family planning services. You can also visit one of our family planning providers.

You do not need a referral from your PCP for family planning services. Family planning services include:
  • Birth control
  • Birth control devices such as IUDs, implantable contraceptive devices and others that are available with a prescription
  • Emergency contraception
  • Sterilization services
  • HIV and sexually transmitted infection (STI) testing, treatment and counseling
  • Screenings for cancer and other related conditions

Children's screening

You do not need a referral to get children's screening services or school-based services.

Local health department services

You do not need a referral to get services from your local health department.

Behavioral health services

You do not need a referral for your first behavioral health or substance use disorder assessment completed in a 12-month period. Ask your PCP or call Member Services at 1-855-375-8811 for a list of mental health providers and substance use disorder providers. You can also find a list of our mental health and substance use disorder providers in our provider directory.