A Primary Care Provider or PCP manages your care and helps you maintain your health. Your PCP will give you check-ups and care when you are ill. If needed, your PCP can arrange for you to see a specialist.

There are several kinds of health care providers who may be PCPs:

• Family practice and general practice doctors (who treat adults and children).
• Internal medicine doctors (who only treat adults).
• Pediatricians (who only treat children and teens).
• Certified registered nurse practitioners.
• Certified registered midwives.
• Physician’s assistants.
• Physician specialists.

If you or a family member has a special need and you want to pick a PCP with that need in mind (for example, a PCP whose office is wheelchair accessible), please call the Enrollment Services Hotline at 1-800-440-3989.

The Enrollment Services Hotline can help you find a PCP. Call them at 1-800-440-3989.  When you are determined eligible for MA, you have 14 days to call them and pick a PCP. If you did not pick a PCP within 14 days, ACCESS Plus will choose a PCP for you.

You can change your PCP at any time by calling the Enrollment Services Hotline.

Whenever you have a medical need, call your PCP. Your PCP will make an appointment for you or answer any questions.

Your PCP will be available to you by phone 24 hours a day, 7 days a week. Call your PCP’s office for instructions about how to contact your PCP when the office is closed.

Every person in ACCESS Plus will get an ACCESS Plus ID card to be used with their ACCESS/EBT card. The ACCESS Plus ID card lists your PCP’s name, address and phone number. Show both of these cards when you go to your PCP for care.

If you want to change your PCP for any reason, call the Enrollment Services Hotline at 1-800-440-3989. ACCESS Plus staff will give you the names and addresses of other doctors in your area. You can also ask for a list of Medical Assistance (MA) providers and we will mail one to you. Call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

When you change your PCP, a new ACCESS Plus ID card will be sent to you. It could take up to a week to get the new ACCESS Plus ID card, but you can see your new PCP right away.

Your PCP may ask you to change to another doctor if you disagree with or refuse to go along with the PCP’s treatment plan, or if your PCP feels another provider could better care for you. If this happens, ACCESS Plus will contact both you and your PCP to discuss the reason your PCP is asking you to change doctors. ACCESS Plus will send you a written notice before your PCP can stop treating you. If you do not agree with the reason why your PCP is asking you to change to another doctor, you can file a complaint. You will not have to change doctors until the complaint process is finished.

Sometimes a PCP will stop providing services to MA patients. He/she may decide not to take the ACCESS Card anymore, or they may decide to move out of town. When this happens, you need to pick a new PCP. As soon as ACCESS Plus learns that a PCP is going to stop providing services, we will send a letter to all of the ACCESS Plus Enrollees who go to that doctor. You will be asked to contact the Enrollment Services Hotline at 1-800-440-3989 so they can help you find a new PCP.

When changing your PCP, you will want to ask your PCP to have your records sent to your new PCP. It is also important that you continue any treatment you are already getting. If you need help getting the care you need, call the ACCESS Plus Helpline at 1-800-543-7633.

Your PCP does not know how long it will take to see each person. Please be patient if you have to wait. If you feel you have to wait too long at your PCP’s office, or if you feel you have to wait too long to get an appointment, please call the ACCESS Plus Helpline at 1-800-543-7633.

For a regular check-up, you may have to wait two to three weeks.

When you call, tell the PCP why you need to see him or her. Your PCP will decide if your need for care is urgent. If you are having an emergency, you should call your PCP or go to the Emergency Room.

If you are going to be late for an appointment or cannot make it, call the PCP’s office so you can set a new time or day. Some offices allow “walk-in” visits. This means that you can go without an appointment and still be seen. Walk-ins may have to wait longer to see the PCP. If you want to know if your PCP allows walk-ins, ask the staff.

It is important that you and all your family members who are on MA go to see your new PCP(s) as soon as possible. Get to know your PCP and let him or her get to know you. This way, if you or a family member gets sick, the PCP will be able to give the best care.

To make an appointment with a PCP, call the phone number printed on your ACCESS Plus ID card and ask for an appointment. If you need help scheduling an appointment, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

If you need an interpreter, call your PCP’s office. They will help you. You can also call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

You should see your doctor regularly – not just when you are sick. ACCESS Plus suggests that you see your doctor once a year for a check-up. Here are some things the PCP may do when you visit:

• Check your blood pressure.
• Check your blood sugar (for diabetes).
• Provide a breast exam and PAP smear.
• Give you information on family planning and sexually transmitted diseases.
• Talk with you about substance abuse and mental health.
• Do screenings such as rectal exams for older adults, and referrals for mammograms.
• Speak with you about quitting smoking, eating healthy and other things important to your health.

If you are sick or get hurt, see your PCP as soon as possible. If it is an emergency, call your PCP or go directly to the Emergency Room. If you think you may be pregnant, see your PCP or an OB/GYN right away.

Kids also need to see the doctor regularly for checkups and immunizations. EPSDT is a health care program for kids, teens and young adults (birth through 20 years).

Call the ACCESS Plus toll-free Helpline at 1-800-543-7633 and we will:

• Schedule an EPSDT check-up for kids, teens and young adults (birth through age 20).
• Help with transportation.
• Remind you when the next EPSDT check-up is due.

Your PCP may say you need special medical care. When this happens, your PCP will send you to a specialist. This is called a referral. ACCESS Plus covers health care you get from specialists when:

• The specialist who gives you care is in MA.
• And, your PCP approves care that needs a referral.

Not all specialty services need a referral from your PCP. See the information below to find out which services need a referral by your PCP in order to be covered. If you need help finding a specialist call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

If you get a referral from your PCP, you will not have to pay a bill for these services:

• Personal care (under 21 only).
• Physician services with a specialist (for example, cardiologist, or neurologist).
• Physical therapy, occupational therapy and speech therapy.
• Foot doctor (podiatrist) services.
• Chiropractic services.

Remember, the services MA covers depend on your MA benefits package. To find out what services are covered for you, call the ACCESS Plus Helpline at 1-800-543-7633. Children under 21 get all medically necessary services.

In ACCESS Plus, you do not need a referral for the following services.

• Family planning.
• Pregnancy related services.
• OB/GYN treatment.
• Dental services.
• Eye exams.
• Medical services through the school.
• Mental health services.
• Drug or alcohol treatment.
• Inpatient hospital care.
• Hospice.
• Nursing home or residential care in a medical facility.
• Medical transportation or ambulance.
• Prescriptions.
• True emergency services.
• Diagnostic/laboratory services (like X-rays or blood work).
• Medical equipment.
• Help to stop smoking.

Some MA services require you to pay a small co-pay, but it is important to know that providers cannot bill you for any services covered by your ACCESS Card, or for any unpaid balances for covered services. Providers are also not allowed to send you a bill even if they do not get paid by MA. If you get a bill for a service that you think should be covered, or if you need help finding a MA provider, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

Sometimes you will need to get “prior authorization.” This means getting approval from DPW before you get the service. Some items and services that may need prior authorization are:

• Rental of durable medical equipment (DME).
• Purchase of DME. Orthotics (like back braces, leg braces and arch supports).
• Prosthetics (such as artificial limbs).
• Surgical supplies.
• Certain medications.
• Some types of hospitalization.

In order for the item or service to be approved, it has to be “medically necessary.” See the next topic for more information about medical necessity.

The PCP or specialist will handle the request to DPW for a prior authorization. DPW has 21 days from the date the written request is received to respond. For medications, DPW will make a decision within 24 hours if all necessary information is available. DPW will then let you and the doctor know about the request. If the request is approved, take the notice to a MA provider for the requested service/item. If it is not approved, you have 30 days to file an appeal.

To check your prior authorization requests, call the toll-free Prior Authorization Hotline at 1-800-433-1324. Hotline hours are 9:00 a.m. to 4:00 p.m. Monday through Thursday.

When you call the hotline, you may have to leave a message and someone will call you back in 2-3 business days. You should be ready to give your name, your recipient number, the type of service requested, the date of the request and the prior authorization number if you know it.

A service or item is “medically necessary” if:

• It is covered by MA.
• It is needed for the proper treatment or management of an illness, injury or disability.
• And, it is prescribed, provided or ordered by an appropriate licensed provider in accordance with accepted standards of practice.

DPW will determine if the care and services are medically necessary. To do this, your PCP or specialist must give DPW all needed information in writing.

If you have an emergency, approval for care is NOT needed. Call 9-1-1, or go to the nearest emergency room. If you are not sure whether you have an emergency, you should call your PCP.

If your PCP or specialist recommends that you have non-emergency surgery, you have the right to get a second opinion from another doctor.

Through a second opinion, you should get the information you need to decide whether or not to have the surgery. The second opinion should also give you information about other treatments and the pros and cons of those treatments.

To get a second opinion, call your PCP or the ACCESS Plus toll-free Helpline for a referral at 1-800-543-7633.

The health services that a woman gets from a doctor, nurse or nurse midwife before the birth of a baby are known as “prenatal care.” Prenatal care is very important. It is a way of seeing how well the pregnancy is going and if there are any problems. Even if a woman has been pregnant before, prenatal care is important.

If you think you are pregnant and need a pregnancy test, see your PCP or a MA family planning provider. If you are pregnant you can:

• Call or visit your PCP, who will help you find a prenatal care provider.
• Visit a MA OB/GYN or nurse midwife on your own.
• Visit a MA health center that offers family planning services.

The ACCESS Plus Program has a list of OB/GYNs, nurse midwives and family planning centers that take MA. To get a copy of this list, or if you need more help finding an OB/GYN or making an appointment, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

It is best for you to get care as soon as you think you might be pregnant.

You should also talk with your PCP when you find out you are pregnant. Your PCP may have information about your health that your prenatal care provider needs to know.

Getting regular prenatal care throughout your pregnancy and using the same provider for all your prenatal care is best. It is also important to see your doctor after the baby is born.

ACCESS Plus provides family planning services and supplies. This includes counseling and birth control. You can get this care from your PCP, a MA family planning provider or any doctor or clinic that takes MA. You do not need a referral from your PCP.

If you need help finding family planning services, call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

WIC is a special program that helps you and your baby eat well. WIC starts when you are pregnant and goes until your child is five years old. It is important that babies and young children eat right. This helps them grow up healthy and strong. WIC can teach you about good nutrition and provide you with coupons to buy food.

For more information about WIC, ask your PCP or call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

Kids also need to see the doctor regularly. EPSDT is a health care program for kids, teens and young adults (birth through 20 years).

An EPSDT check-up includes:

• Complete physical exam.
• Hearing test.
• Vision test.
• Developmental screening.
• Lab work (blood and urine tests).
• Immunizations (shots that keep kids from getting sick).
• Complete health history and education on staying healthy.

Call the ACCESS Plus toll-free Helpline at 1-800-543-7633 and we will:

• Schedule an EPSDT check-up.
• Help with transportation.
• Remind you when the next EPSDT check-up is due.

If a problem is found during the EPSDT check-up, your PCP can refer you to a specialist. Those under the age of 21 may be able to get things like a hearing aid, eyeglasses and braces for teeth.

The Commonwealth of Pennsylvania has programs and services for babies to school age children who have developmental delays or disabilities. It is best to get involved as soon as you think your child may have a physical or emotional developmental problem. Early intervention may make a difference.

If you have any questions or concerns about your child’s development (physical, emotional or other), please talk with your child’s PCP about them.

If you want more information about early intervention services or need help getting these services, call the ACCESS Plus toll-free Helpline at 1-800-543 7633.

MA covers all medically necessary dental services for enrolled children from birth through age 20. This includes:

• Teeth cleaning.
• X-rays.
• Cavity fillings.
• Crowns.
• Other services.

Whether or not adults on MA have dental services covered by ACCESS Plus depends on their MA benefits package and their medical need for the services. You can find out whether MA covers dental services for you by calling the ACCESS Plus toll-free Helpline at 1-800-543-7633.

If you have dental coverage, you can visit any MA dentist. For help finding a dentist or making an appointment, call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

Whether or not adults on MA have vision services covered by ACCESS Plus depends on their MA benefits package and their medical need for the services. You can find out whether MA covers vision services for you by calling the ACCESS Plus toll-free Helpline at 1-800-543-7633.

All ACCESS Plus enrollees under 21 years of age may get eye exams. You do not need a referral for eye exams. You can make an appointment with any MA vision care provider.

To see an eye specialist (called an ophthalmologist) because of eye disease or eye injury, you do need a referral from your PCP.

If you need help finding an eye doctor, or if you have any questions, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

If prescription drugs are covered by your MA benefits package, you can get your prescriptions filled through ACCESS Plus.

• Children (under 21) are covered for all medically necessary prescription drugs.
• Adults on MA may or may not have prescription coverage, depending on their benefits package. In addition, some MA recipients must pay a co-pay on their medications.

If you want help determining whether or not MA will cover your drugs or whether or not you will have to pay a co-pay, call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

To get your medications through ACCESS Plus, you will need a prescription from your PCP or MA specialist. Many over-the-counter drugs may also be covered as long as you have a prescription. Your benefits package will determine if you have a co-pay or not. It will also determine the number of prescriptions you can get filled. Call the ACCESS Plus toll-free Helpline at 1-800-543-7633 if you need help finding a pharmacy or if you have any other questions.

Note: Your PCP or specialist will call for prior authorization. DPW will make a decision within 24 hours if all necessary information is available. If the authorization is approved, your doctor will put the authorization number on the prescription. If the authorization is denied, you have 30 days to file an appeal.

If you or your child has been diagnosed with one or more of these chronic conditions, you are eligible for “disease management” services:

• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Coronary Artery Disease (CAD)
• Diabetes

Disease management helps you and your PCP manage your disease and keep you as healthy as possible. Enrollees who are eligible for Disease Management services can be identified:

• Through the ACCESS Plus enrollment process;
• Through a referral from their medical provider; or
• By calling the ACCESS Plus toll-free Helpline and identifying yourself.

If eligible we will mail you information about the Disease Management Program for your condition. You will be contacted to participate in the Program. Your participation in Disease Management is voluntary.

If you agree to participate in Disease Management, ACCESS Plus will work with you to develop an individual care plan based on your needs. These are some of the services you can get through Disease Management:

• Treatment support and follow up to remind you to make and keep medical appointments or re-fill your prescriptions.
• Help coordinating your care if you are hospitalized or if you need to go into a nursing home or rehabilitation facility.
• Educational materials/programs/videos to help you understand and manage your disease.

Call the ACCESS Plus toll-free Helpline at 1-800-543-7633 if you want to know more about Disease Management.

ACCESS Plus is focused on your physical health care. If you need mental health treatment, you should get in touch with your county’s MH/MR program. If you need drug or alcohol treatment, you should get in touch with your county’s Drug and Alcohol Program.

For help getting any of these services call the ACCESS Plus toll-free Helpline at 1-800-543-7633. If you receive behavioral health services you should tell your PCP. Your PCP must coordinate the care they give you with the care you get from your behavioral health providers. This includes sharing clinical information, providing health records when asked, and being able to talk with your behavioral health providers.

If you have HIV or AIDS, and you are eligible, you may get one or more of the following:

• Targeted Case Management to help you get medical and social support services.
• The AIDS Waiver Program to help you stay at home and out of a hospital or nursing home.
• The Special Pharmaceutical Benefits Program to help pay for specific HIV/AIDS treatment drugs.

Please call the ACCESS Plus toll-free Helpline at 1-800-543-7633 if you want to know more about these services or if you need help with making an application for these services.

ACCESS Plus has care coordination services available to help you if you or any of your children have special needs. You are considered to have “special needs” if, for example, you:

• Need extensive health care or services.
• Need special equipment or services.
• Need help with language, communication or transportation.

If you tell us about your special need, a care coordinator will contact you directly to see that your special needs are addressed. These are some of the things our care coordinators can do:

• Help you get Disease Management Services
• Help you contact the Medical Assistance Transportation Program and arrange transportation to your appointments.
• Help you contact and arrange for interpreters if you are deaf/hard of hearing, or if you do not speak or understand English.
• Help you locate providers who are physically accessible/able to address your special needs.

If you need help with your special needs call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

If it is hard for you to get to your medical appointments, your county’s Medical Assistance Transportation Program (MATP) can help you get a ride to your doctor/clinic or pay you for your travel. To qualify, call the office listed below for your county. MATP does not include ambulance service.

If you need help contacting your county’s MATP or scheduling transportation with them, or if you want to find out about other transportation options, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

You have the right to make medical care decisions even when you can’t speak for yourself. You should have an Advance Directive so your doctor will know what you want done or not done if you can’t talk. An example of an Advance Directive is a living will.

For more information on Advance Directives, please visit http://www.portal.state.pa.us/portal/server.pt/document/780893/advancedirectives_pdf

ACCESS Plus wants you to get the best possible service. When something goes wrong, we want to know.

Step 1
If you have a problem or complaint about your PCP, Disease Management, ACCESS Plus, or the service you have received, you can call the ACCESS Plus toll-free Helpline at 1-800-543-7633 and tell us. Or, you can put your complaint in writing to us at:

ACCESS Plus
100 Sterling Parkway, Suite 201
Mechanicsburg, PA 17050

Step 2
We will make a record of your complaint. We will have someone not involved with the matter you are complaining about review your complaint and try to find a solution. Your satisfaction is important to us.

Step 3
We will then send you a written response within 30 days of receiving your complaint. If you are not satisfied with the answer, you may write to:

Department of Public Welfare
ACCESS Plus
P.O. Box 8044
Harrisburg, PA 17105-8044

Someone from DPW will review the matter and follow up with you directly.

If you have a problem with a denial, reduction or termination of a health care service, you may appeal to DPW and request a Fair Hearing. Your appeal must be in writing. DPW must get your appeal within 30 days of the date of the notice about the denial, approval of a different service, or a decrease in services.

If services you are already getting are being reduced, denied or approved for a different service, you may want to have the services continue during your appeal. To do this, you must file your appeal to DPW within 10 days from the date on the notice from which you are appealing.

You must send your DPW Fair Hearing Appeal to:

Department of Public Welfare
Appeals Section
P.O. Box 8171
Harrisburg, PA 17105

As long as you live in an ACCESS Plus county, you must be enrolled in ACCESS Plus. You will get your care through that program unless you fit into one of the groups that is exempt from ACCESS Plus.

MA recipients are exempt from ACCESS Plus if they are:

At ACCESS Plus, we are committed to keeping your “protected health information” private. Some examples of protected health information are:

• Your Name (and the names of your children or other household members on MA).
• Your Telephone Number.
• Your Address.
• Your DPW Recipient Number.
• Your Date of Birth.
• Your Social Security Number.
• Your Admission/Discharge Date.
• Your Medical Procedure Code.
• Your Diagnostic Code.

There are times that ACCESS Plus will need to share your protected health information with other persons who are responsible for your care. Some examples of when we can share information are:

• To help you get medical care.
• To arrange payment for your care and services.
• For operating ACCESS Plus (such as using the information to remind you about an appointment).
• If we are required by law.

For more information on ACCESS Plus privacy practices, please call the ACCESS Plus toll-free Helpline at 1-800-543-7633.

As a member of ACCESS Plus you have the right to:

• Be treated with respect and regard for your dignity and privacy.
• Receive the names, addresses and telephone numbers of PCPs in your service area, to know what languages are spoken by those PCPs, and to know which PCPs are physically accessible.
• Know which PCPs are taking new patients and which are not.
• Pick a new PCP any time for any reason.
• Be able to call your PCP and get help 24 hours a day, 7 days a week.
• Know that your medical records and any talks with your PCP are private.
• Ask for and get a copy of your medical records from your providers, and ask that they be corrected if necessary.
• Have your PCP explain your treatment, your choices for treatment and any follow-up that is needed in a way that makes sense to you.
• Have your PCP coordinate your care with any care you may be getting from behavioral health providers.
• Make decisions about the care you get, and that includes saying “no” to any care you don’t want.
• Ask questions and have them answered by your PCP.
• Receive case management and care coordination services from ACCESS Plus if you need them.
• Get help with coordinating your care if you are someone with special needs.
• Tell ACCESS Plus or DPW about any complaints or problems you have with how you are treated by ACCESS Plus or with the care you get. You may write a letter or call.
• Appeal in writing any decision to deny, reduce or terminate health care services and have a DPW Fair Hearing.
• Exercise your rights without fear of retaliation by your PCP or other health care providers.
• Get information in a different language or in a different way at no cost to you. This includes relay services, oral interpreters for all non-English languages, or other ways if you are visually impaired or if you or your family cannot read. The information should also tell you how your PCP will help you get these services.
• Be told of any change made by the Department of Public Welfare to ACCESS Plus at least 30 days before the change takes place.

You have the responsibility to:

• Learn your rights as an ACCESS Plus member.
• Carry your ACCESS Plus Member ID card at all times.
• Keep all your scheduled appointments and cancel all appointments you cannot keep in advance.
• Treat your PCP with respect.
• Tell your PCP about your health care needs and about any other health care services you are receiving.
• Keep up-to-date on immunizations (shots).
• Contact your PCP first for care that is not an emergency.
• Get a referral from your PCP before getting care that requires a referral.
• Tell your PCP about other services you access that do not require a referral.
• Let your case worker know about important changes (such as changes in your name, address, phone number, and income or family size) by calling your local County Assistance Office.
• Share important information that is needed by your providers.
• Follow the instructions and guidelines given by the professional staff providing covered services.
• Get information about ACCESS Plus and covered services.
• Choose your provider.
• Refuse treatment from specific providers.
• Have a PCP who is acting within the lawful scope of practice that will advise or advocate for appropriate care.
• Have advance directives and share them with your providers.

Sometimes, people try to get too many services or drugs they do not need. When this happens, the Department of Public Welfare puts that person in the Recipient Restriction/“Lock-In” Program. When someone is in the “Lock-In” Program they can still get all of the services available through their ACCESS Card, but they will have to go to a single doctor, pharmacy, hospital or other MA provider that has been picked by the Department.

If this happens, the doctor that the Department chooses will be your ACCESS Plus PCP. If you are in the “Lock-In” Program you must work directly with the Department of Public Welfare’s Bureau of Program Integrity to find a suitable provider.

ACCESS Plus – A health care program in which you pick a PCP. This PCP gives you most of your medical care. You will need a referral from your PCP to see some specialists. ACCESS Plus is for people who get their health care through the ACCESS/EBT card.

Care Coordination – ACCESS Plus will help you coordinate care for medical, social, educational and other services you need. For example, ACCESS Plus will help you find transportation to your medical appointments.

Co-pay – Short for “co-payment.” This is a small fee that you may have to pay for some services, like prescription drugs. Your co-pays depend on your age and benefits package.

Covered Service - The services you can get under ACCESS Plus depend on your MA benefits package. For example, coverage for prescription drugs, medical equipment and dental services are provided to some persons on MA but not to others. Call the ACCESS Plus Helpline at 1-800-543-7633 to find out what services are covered for you.

DPW (The Department of Public Welfare) – This is the agency that runs the Medical Assistance (MA) Program.

Disease Management – Extra services you can get if you have a chronic disease (like asthma, diabetes and heart disease). Extra services may include educational programs and videotapes about your disease or specialized case management to help meet all of your health care needs. These services help you manage your disease and stay as healthy as possible.

EPSDT – Check-ups for kids, teens and young adults (birth through age 20).

Helpline – The ACCESS Plus toll-free Helpline you can call from 7:00 a.m. to 8:00 p.m. Monday through Friday, and Saturday 10:00 a.m. to 2:00 p.m.

Immunizations – Shots that stop sickness like measles, mumps and chicken pox.

Lab Work – Blood or urine tests for illness.

Prenatal Care – Care that is given to a pregnant woman the whole time she is pregnant. This care is important for the mom and unborn child’s health.

Primary Care Provider or PCP – A doctor, clinic or other health care professional who handles all of your health care needs like a check-up, shots, blood work and medicine when needed. The PCP will also answer medical questions. The PCP can be reached 24 hours a day, 7 days a week.

Prior Authorization – A process in which DPW reviews a prescription for a health service or medication and any related documents to decide whether or not to approve the prescription before the service/medication can be covered under MA.

Referral – When your PCP sends you to a specialist for care.

Specialist – A doctor who practices a special kind of medicine, like an ear, nose and throat doctor, or a foot doctor.