For members of the Primary Care Clinician (PCC) Plan, all services need a referral from your PCC, unless the services were provided by your Primary Care Clinician, or are in the section below.
Services that do not need a referral in the PCC Plan
Abortion services |
Services delivered by a dentist |
Annual gynecological exams |
Services delivered by a family planning service provider, for members of child-bearing age |
Clinical laboratory services |
Services delivered by a hospice provider |
Diabetic supplies |
Services delivered by a limited service clinic |
Durable medical equipment (items, supplies, and equipment) |
Services delivered in a nursing facility |
Fiscal intermediary services |
Services delivered by an anesthesiologist |
Fluoride varnish administered by a physician or other qualified medical professional |
Services delivered in an intermediate care facility–intellectual disability (ICF-ID) |
Functional skills training provided by a MassHealth personal care management agency |
Services delivered to a homeless member outside of the PCC office |
HIV pre- and post-test counseling services |
Services delivered to diagnose and treat sexually transmitted diseases |
HIV testing |
Services delivered to treat an emergency condition |
Hospitalization |
Services provided under a home- and community-based waiver |
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)) |
Sterilization services when performed for family planning services |
Non-elective admissions |
Surgical pathology services |
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) |
Tobacco-cessation counseling services |
Oxygen and respiratory therapy equipment |
Transportation to covered care |
Pharmacy services (prescription and over-the-counter drugs) |
Vision care in the following categories (see Subchapter 6 of the Vision Care Manual):
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Radiology and other imaging services with the exception of
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Services delivered in an urgent care clinic |
These all do require a referral:
Services delivered by a behavioral health (mental health and addiction) provider, including inpatient and outpatient psychiatric services
Call MassHealth at call 1-800-841-2900 (TTY: 1-800-497-4648) with questions about referral requirements.