Services That Require an OK

Your benefits cover the most common types of care. Other types may require a referral from your PCP and an OK from us.

For example, you may need to see a specialist who treats a certain disease or part of the body. Your PCP may make that request. That’s called a referral. But even with a referral, you may still need an OK from us for certain kinds of care. An OK is called a prior authorization, and your provider has to request an OK.

Most providers know what services need an OK from us, and they’ll call before providing these services. You have every right to ask them to call us. You can even call us yourself.

Remember – emergency care doesn’t require an OK.

It's especially important to ask for an OK for:

  • Inpatient hospital admissions and services
  • Outpatient hospital services, tests and procedures
  • Services from a health care provider not in our network
  • Mental health and substance use disorder treatment
  • Bariatric surgeries for weight loss
  • Chiropractic services for children (available only for members under 21)
  • Durable Medical Equipment (purchase or rental of more than $500)
  • Home Health Care
  • Hospice Care, inpatient and outpatient
  • Imaging services including MRIs, PET Scans and Nuclear Cardiology
  • Orthotics (purchase amount/allowed amount of more than $200)
  • Outpatient Therapy (Physical, Occupational & Speech)
  • Plastic Surgery
  • Pregnancy care
  • Prosthetics (purchase amount/allowed amount of more than $200)
  • Skilled Nursing Facility
  • Transplants and related services
  • Wheelchairs (any cost or rental fee)

Some pharmacy medicines also need an OK. These may include certain shots or medicines given by IV. Your provider will have to get an OK from the TennCare Pharmacy Program before prescribing them. Ask your provider to help you make sure all your medicines are covered by your plan.

Some mental health and substance use disorder treatment may also need an OK, even though they don’t need a referral from a PCP. Ask the provider to get an OK from us before you get this kind of treatment.

This is not a complete list of care, services, products and pharmacy medicines that require an OK from us. If you have questions, please call or email Customer Service.