See your doctor
Your primary care provider (PCP) is the doctor that will help you get the health services you need. You should schedule an appointment as soon as you choose your doctor. Your PCP can help you with:
- Wellness checkups and screenings
- Vaccines
- Advice about how to prevent disease
- Sick visits, like a fever or flu
- Chronic conditions, like diabetes or asthma
- Medical tests to help diagnose your condition
- Referrals to specialists or special medical tests
It is good to see your doctor regularly. When you get to know your doctor and your doctor gets to know you, they can more easily see if you have a health problem before it gets worse.
Getting care from a specialist
When you need care from a specialist your doctor will refer you. In some cases your doctor may need to order tests to find out what kind of specialist you will need to see. Some specialists need pre-approval from KFHC. Some tests need a referral sent to KFHC so we can review the request and approve the test.
The following services always need pre-approval (prior authorization), even if you get them from a provider in the KFHC network.
- Hospitalization, if not an emergency
- Services out of the KFHC network, if not an emergency or urgent care
- Outpatient surgery
- Long-term care or skilled nursing services at a nursing facility
- Specialized treatments, imaging, testing, and procedures
- Medical transportation services when it is not an emergency
- Some physician administered drugs given in provider offices including those injected or infused (given through a fluid in the vein) as appropriate
- Some vaccines not recommended by the Advisory Committee on Immunization Practices (ACIP)
When your doctor knows what specialist you need to see they will send us a referral request. The referral review process works like this:
- The referral is reviewed and a decision is made within 5 business days
- If your doctor feels your condition is urgent, they will send us an urgent referral request which is done within 72 business hours
- You will get a letter from us when the decision is made
- Your approval letter will tell you what specialist you are approved to see or what kind of test you are approved for
- Call your specialist or the testing facility to make your appointment as soon as you get the letter
- If you are denied for the service you can appeal the decision and your letter will tell you how
If you need help with your referral or have questions about the appeal process, please call Member Services at (800) 391-2000 TTY 711, Monday through Friday from 8:00 am to 5:00 pm.