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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)

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.

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