Referrals for services in MassHealth PCC Plan

The role of your PCC and other providers in the referral process and which services that do not require a referral

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): Visual analysis frames Single-vision prescriptions Bifocal prescriptions, and Repairs
Radiology and other imaging services with the exception of Magnetic resonance imaging (MRI) Computed tomography (CT) scans  Positron emission tomography (PET) scans, and Imaging services conducted at an independent diagnostic testing facility (IDTF)
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.