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Referrals & Authorizations
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PHPSM does not require a referral from the PCP (Primary Care Physician) if you see another physician within the PHPSM network. If you wish to see a specialist, you may self-refer to any specialist within the PHPSM network.
It is important to note that while PHPSM does not require a referral to a physician within our network, there are certain specialists who will ask for a referral from the PCP before setting up an appointment. PHPSM supports that process, as we feel it is within your best interest to coordinate your healthcare through your Primary Care Physician. This way, there is one medical professional that is aware of your total health history and can be helpful in coordinating your total care.
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What services do not require a referral?
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- Any services provided by a physician within our network, including:
- Specialist visits
- Routine vision examinations
- General pediatric care for minors
- Emergency or urgently needed health services
Members who wish to change their PCP may do so by calling the Customer Service Department at (517) 787-6865 or (800) 394-7569.
Access to services outside of the PHPSM Network falls into two categories:
- Emergency Care
- Non-Emergency Care
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Emergency Care
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All Standard PHPSM benefit plans cover worldwide emergency care. If you have a sudden illness that will worsen if not treated immediately, you can access a physician’s office, urgent care facility or emergency room. If possible, call your primary care physician before your emergency room visit for assistance, to ensure care is appropriate. If you need assistance, please call the PHPSM Care Management Department at (888) 807-7633 or (517) 782-8238 Monday through Friday from 8 a.m. to 5 p.m. or the on-call Nurse Advisor at (888) 374-8127.
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Non-Emergency Care
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Except in an emergency, medically necessary and preventive healthcare services must be provided, arranged or authorized through PHPSM and its participating physicians. All referrals to non-PHPSM providers require prior plan authorization. Failure to request prior authorization when required may result in reduced benefits, and in some instances benefits may be denied. At times, a Primary Care Physician will refer a member to a non-participating provider. It is the member’s responsibility to contact PHPSM to request authorization to see a non-participating provider.
To request authorization to see a non-participating provider, please call the PHPSM Care Management Department at (888) 807-7633 or (517) 782-8238 Monday through Friday from 8 a.m. to 5 p.m.
Click here for more information on emergencies, non-emergencies and urgent care.
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