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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 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.

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.

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.

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.