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Medical Care and Plan Providers
Care from Specialists
When your PCP thinks that you need specialized treatment, he or she will give you a "referral" (approval ahead of time) to see a plan specialist. A "specialist" is a doctor who provides health care services for a specific disease or part of the body. Some examples of specialists include oncologists who treat cancer; cardiologists who treat heart conditions; and orthopedists who treat certain bone, joint, or muscle conditions. For some types of referrals to plan specialists, your PCP may need to get approval ahead of time from our Medical Management Department. This is called "prior authorization".
It is very important to get a referral from your PCP before you see a plan specialist. However, you do not need to get a referral for certain services. See Medical Services Not Requiring a Referral. If you don't have a referral before you get services from a specialist, you may have to pay for these services yourself. If the specialist wants you to come back for follow-up visits, be sure to check the original referral to see if these were included.
Each plan PCP has certain plan specialists they use for referrals. This means that the Essence specialists you can use may depend on which person you choose to be your PCP. If there are specific specialists you want to use, find out whether your PCP refers patients to these specialists. If you want to change your PCP, see Choosing or Changing PCP on this website. If there are specific hospitals you wish to use, find out whether your PCP uses these hospitals.