Referrals for Care

 McLaren Health Plan cares about you and your health.  You have picked a Primary Care Physician (PCP) to handle your concerns, questions, and driect the care you need.  McLaren Health Plan has a referral process that helps your PCP know what is going on with you.

You do not need a referral from you PCP to visit or receive treatment in the office of an In-Network specialist.  It is recommended that you continue to consult with you PCP who can help direct you to the most effective, high quality care, and oversee ongoing coordination of your health.  Your PCP will be responsible for working with McLaren Health Plan and starting the referral process, when necessary.

There are some services that require referrals.  These requests are subject to medical review by McLaren Health Plan who will make an authorization decision and return the referral to the requesting practitioner.

Customer Service can assist you in obtaining pricing information for covered services; this pricing information does not guarantee approval of an authorization request.

Here is a list of services requiring pre-authorization from McLaren health Plan:

  • Inpatient Services
  • Ambulatory Outpatient Surgery
  • All Out-of-Network Services
  • Any Potentially CosmeticServices, such as, but not limited:
    • Abdominoplasty
    • Bariatric Surgery
    • Blepharoplasty
    • Breast Reduction
    • Botox Injections
    • Panniculectomy
    • Scar Revisions
  • Dental/Oral Procedures – Medical Diagnosis Only
  • Durable Medical Equipment (Purchase Price greater than $1500, rental greater than $500/month)
  • Extended Care Facility (ECF)
  • Home Health Care
  • Infertility Testing and Services
  • Injectables/IV Therapy
  • Insulin Pumps/Supplies
  • Prosthetics and Orthotics (Purchase greater than $500)
  • Proton Beam Therapy
  • Rehabilitative Facility Services (Example:Cardiac and Pulmonary)
  • Sub-Acute Care
  • Therapies (Physical, Occupational, and Speech)*
  • Transplant Care

*Contact Customer Service at (888) 327-0671 for Therapy Limits and Authorization requirements

For your conveniences, there is a list of CPT codes that require pre-authorization in the Outpatient Setting.  This list is available here: Referral Categories

Any care received by an Out-of-Network provider requires pre-authorization.  Only those services, which are approved by McLaren Health Plan prior to receiving Out-of-Network care, will be covered.  If a pre-authorization is denied, you will receive a decision in writing from McLaren Health Plan with an explanation for the denial.

If you have any questions about referrals for specific services, including pricing, benefits or financial responsibility, please call Customer Service at (888) 327-0671.