For members of the Primary Care Clinician (PCC) Plan, all services need a referral from your PCC, unless the services were provided by a Primary Care Clinician.

New services that need a referral starting on October 1, 2016:

  • Chiropractic Services
  • Orthotic Services
  • Prosthetic Services
  • Hearing Instrument Specialist Services
  • Imaging Services conducted at an Independent Diagnostic Testing Facility (IDTF)
  • Medical Nutrition Therapy/Diabetes Nutrition Management Training

 

These services do not need a referral:

  • abortion services
  • annual gynecological exams
  • clinical laboratory services
  • diabetic supplies
  • durable medical equipment (items, supplies, and equipment)
  • fiscal intermediary services
  • fluoride varnish administered by a physician or other qualified medical professional
  • functional skills training provided by a MassHealth personal care management agency
  • HIV pre- and post-test counseling services
  • HIV testing
  • hospitalization
  • elective admissions (All elective admissions are exempt from the PCC referral requirement and are subject to the MassHealth agency’s admission screening requirements at 130 CMR 450.208(A))
  • non-elective admissions
  • obstetric services for pregnant and postpartum members (provided up to the end of the month in which the 60-day period following the termination of pregnancy ends)
  • oxygen and respiratory therapy equipment
  • pharmacy services (prescription and over-the-counter drugs)
  • radiology and other imaging services with the exception of magnetic resonance imaging (MRI) computed tomography (CT) scans, and positron emission tomography (PET) scans, and imaging services conducted at an independent diagnostic testing facility (IDTF), which do require a referral
  • services delivered by a behavioral health (mental health and substance abuse) provider (including inpatient and outpatient psychiatric services)
  • services delivered by a dentist
  • services delivered by a family planning service provider, for members of child-bearing age
  • services delivered by a hospice provider
  • services delivered by a limited service clinic
  • services delivered in a nursing facility
  • services delivered by an anesthesiologist
  • services delivered in an intermediate care facility for the mentally retarded (ICF-MR)
  • services delivered to a homeless member outside of the PCC office pursuant to 130 CMR 450.118(K)
  • services delivered to diagnose and treat sexually transmitted diseases
  • services delivered to treat an emergency condition
  • services provided under a home- and community-based waiver
  • sterilization services when performed for family planning services
  • surgical pathology services
  • tobacco-cessation counseling services
  • transportation to covered care
  • vision care in the following categories (see Subchapter 6 of the Vision Care Manual):  visual analysis frames, single-vision prescriptions, bifocal prescriptions, and repairs
  • additional services provided to members whose PCC participates in an Accountable Care Organization (ACO); subject to bulletins and other issuances more particularly describing applicable referral requirements

*Please see 130 CMR 450.000 for the most up-to-date list of PCC referral exceptions.

 


This information is provided by MassHealth.