The doctor will talk to you about your/your child’s needs and will help make plans for you to see the specialist that can provide the best care for you. This is called a referral. Your/your child’s doctor is the only one that can give you a referral to see a specialist. If you/your child has a visit, receives services from a specialist without your doctor’s referral, or if the specialist is not a Superior provider, you might be responsible for the bill. In some cases, an OB/GYN can also give you a referral for related services.
Some specialist referrals from your/your child’s doctor may need approval from Superior to make sure the specialist is a Superior specialist, and the visit to the specialist or the specialty procedure is needed. In these cases, the doctor must first call Superior. If you or your doctor are not sure what specialty services need approval, Superior can give you that information. Superior will review the request for specialty services and respond with a decision. Decisions are made more quickly for urgent care.
You do not need a referral for:
- True emergency services
- OB/GYN care.
- Behavioral health services.
- Routine vision services.
- Dental services (for children).
- Family planning services.
Finding a doctor or dentist who accepts Medicaid and practices in their area used to be a chore for Medicaid recipients, as well as their primary care physicians. Now, that information can be found via a quick computer search.
The Medicaid program’s Web site, www.medicaid.dhh.louisiana.gov, now features a Provider Locator Map that allows users to search for Medicaid providers by parish or region. Users can pick what sort of service they need (i.e. vision services, foot specialists, mental health services) and be given a list of all providers for that service in their area who are enrolled in Medicaid.
“We often hear complaints from our Medicaid recipients or their primary care physicians that they have trouble finding a provider for a specialized service who accepts Medicaid,” said LDH Secretary Dr. Fred Cerise. “With this new search tool, it will be easier and faster for recipients to locate a provider in their area, and it will be easier for their primary care doctors to refer them to another provider.”
To access this feature, users should go to the site and click on the magnifying glass that says "Find a doctor or dentist in Medicaid." They will then be directed to the map, which will allow them to select a service from a drop-down menu and click on either their region or their parish to search. The map gives users the name, address and phone number of all providers that fit their search criteria. If no active provider is listed in a user’s parish for service, they are advised to check the surrounding parishes or the entire region.
It is important for clients to remember that this tool is only intended to be a starting point when looking for a Medicaid Provider and that just because a provider is listed on the site does not guarantee the recipient will be able to get an appointment. While all of the providers listed are "active," not all of them will be accepting new patients.
Medicaid staff are reminding recipients that they should always check with the listed provider to see if he or she is taking new Medicaid clients and/or seek referrals from their CommunityCARE primary care physicians before scheduling an appointment.
“We have made greater strides this year in making our programs and services more accessible to the public through our Web site,” Cerise said. “Since April, we have launched a restaurant inspections ratings site and a nursing home inspections ratings site to give people more information. Like those sites, this addition to our Medicaid site will ease the process for recipients seeking treatment and will enable them to receive the medical services they need in a faster and more efficient manner.”
Recipients who are unable to find a provider through this service should call the KIDMED/ CommunityCARE Referral Assistance Hotline at 1-877-455-9955 for help.
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As a Medicaid or NC Health Choice beneficiary, you fall into one of three categories: To learn more about NC Medicaid Managed Care, go to the
NC Medicaid Managed Care Website. Some beneficiaries can choose to stay in NC Medicaid Direct. This means you are not required to choose a health plan and a PCP. NCDHHS - Division of Health Benefits will send you a letter that tells you if you have the
choice to enroll. You have the option to choose a health plan if you:NC Medicaid Managed Care – Mandatory
Most beneficiaries receiving Medicaid or NC Health Choice will be required to transition to NC Medicaid Managed Care. This means you must choose a health plan and a Primary Care Provider (PCP). If you must choose, NCDHHS - Division of Health Benefits will send you a letter that tells you how to transition to Managed Care. You will be required to transition to NC Medicaid Managed Care if you:NC Medicaid Managed Care – Exempt
- Are a federally-recognized tribal member or individual eligible for services through Indian Health Service (IHS).
- Need certain services to address needs related to developmental disability, behavioral health or traumatic brain injury. BH covers MH and SUD
NC Medicaid Managed Care – Excluded (NC Medicaid Direct)
- Some
beneficiaries will remain in NC Medicaid Direct, which is the “fee-for-service” program. This is how you receive health care services now. This means you cannot choose a health plan and you do not need to choose a new PCP unless you want to change to your current PCP. You will stay in NC Medicaid Direct if you:
- Receive Family Planning Medicaid, Refugee Medicaid, Foster Care/Adoption Medicaid , or must meet a deductible before getting Medicaid benefits
- Are part of the Health insurance premium payment (HIPP) or Program of all-inclusive care for the elderly (PACE) programs, or
- Have both Medicare and Medicaid or receive long-stay nursing home services,
- Receive Innovations Waiver services, Traumatic Brain Injury (TBI) Waiver services, or Community Alternatives Program for Children (CAP/C) or Community Alternative Program for Disabled Adults (CAP/DA) services.