Copays, Prior Authorizations and Referrals
Medical and Behavioral Health Care Services
When you need health care, always start with a call to your medical or behavioral health provider. You can choose any provider in our behavioral health network. You don’t need a referral from your primary care provider (PCP).
Copayments
Copayments for healthcare services or prescription drugs
are paid to the healthcare provider at the time of service. Absolute Total Care does require member copayments for certain covered and approved medically necessary medical services.
The following Medicaid beneficiaries do not have to make copayments: There are no copays for children under 19 years old, pregnant women, institutionalized individuals (such as a nursing facility) or members of
a federally recognized tribe when services are rendered by the Catawba Service Unit in Rock Hill, SC and when referred to a specialist or other medical provider by the Catawba Service Unit. There are no copayments for preventive care such as well-child or well-baby visits or vaccines.
The table below lists the Absolute Total Care copayment schedule. For a complete list of services or questions regarding a specific service or copay please contact Member Services at 1-866-433-6041 (TTY: 711).
Prior Authorization and Referrals
Some covered services or medications may need approval from Absolute Total Care. This is called a prior authorization. You do not need a paper referral from Absolute Total Care to see a provider, but your provider may need to request a prior authorization from Absolute Total Care for a service to be approved. Below is a list of services that require prior authorization from Absolute Total Care before your healthcare provider can proceed with treatment.
- A prior authorization is not required for emergency or urgent care services.
- For hospital admissions, your doctor should notify Absolute Total Care within one business day of admission.
Inpatient Hospitalization
Pre-scheduled, optional services must be approved by Absolute Total Care before you are admitted. Your provider will send a request to Absolute Total Care.
How soon can I expect to be seen by a specialist?
In some situations, the specialist may see you right away. Routine visit appointments should be scheduled within four weeks or within twelve weeks for unique specialists.
How do I ask for a second opinion?
You have the right to a second opinion from an Absolute Total Care provider if you are not satisfied with the plan of care offered by the specialist. Your primary care healthcare provider should be able to give
you the name of a provider for a second opinion visit. If your primary care provider wants you to see a specialist that is not an Absolute Total Care provider; that visit will have to be approved in advance by Absolute Total Care.
Non-Participating/Out-of-Network Providers
Requests for services from a provider, facility, or vendor that is not in the Absolute Total Care network needs to be approved by getting a prior authorization.
Your healthcare provider can tell you if a medical service or prescription needs prior authorization. The list below gives you general categories of services requiring prior authorization. Please keep in mind that services and benefits change from time to time. This prior authorization list is for your general information only. Please call Absolute Total Care Member Services for the most up to date information at 1-866-433-6041 (TTY: 711).
Copayment and Prior Authorization Schedule*
| Benefit | Coverage | Limits | Authorization Requirements | Copay |
|---|---|---|---|---|
Abortion Procedure | Covered | Covered according to applicable federal and state laws and regulations. Written physician certification of the need for the abortion required. | $0 | |
Acne | Covered | Ages 18 and younger. Limits apply. | $0 | |
| Acupuncture & Biofeedback Service | Not Covered | N/A | N/A | |
| Ambulance Services - Emergency and Non-Emergency | Covered | $0 | ||
| Ambulatory Surgical Center | Covered | Copay is applied per day. | Prior Approval may be required for some services. | $3.30 |
| Autism Spectrum Disorder (ASD) Treatment Services | Covered | $0 | ||
| Audiology Services | Covered | Ages 20 and younger. | $0 | |
| Bariatric Surgery - Surgery for Morbid Obesity | Covered | Prior approval required. | $0 | |
| Behavioral Health - Evaluation (Outpatient | Covered | One evaluation every six months. | $0 | |
| Behavioral Health - Medical Office Visit (Psychiatrist or Nurse Practitioner Only) | Covered | Psychiatrist or nurse practitioner only. | $0 | |
| Birthing Centers | Covered | Prior approval required. | $0 | |
| Biopharmaceuticals (specialty injectables) | Covered | Prior approval required. | $3.40 | |
| Cardiac Rehabilitation Services | Covered | Prior approval may be required for some services. | $0 | |
| Chemotherapy Services | Covered | Prior approval may be required for some services. | $0 | |
| Chiropractic Services | Covered | One per day/ six per year. | $0 | |
| Circumcision | Covered | Covered during the initial newborn stay and up to 180 days after delivery in the office setting. Otherwise, prior approval required. | Prior approval may be required. | $0 |
| Clinic Visits | Covered | $0 | ||
| Cosmetic Surgery | Not Covered | N/A | ||
| Dermatology Services | Covered | Cosmetic is not covered. | Prior approval may be required for some services. | $0 |
| Dental Services | Covered by SCDHHS | Covered by SCDHHS/DentaQuest. | N/A | |
| Developmental Evaluation Services | Covered | Covered for members between the ages of 0 and 21. | $0 | |
| Diabetic Shoes | Covered | One pair per year (three inserts per year). | $0 | |
| Diabetic Supplies (Test Strips, Lancets, Pen Needles) | Covered | Quantity limits may apply. | Prior approval may be required. | $3.40 |
| Diabetic Education | Covered | $0 | ||
| Dialysis | Covered | Prior approval required. | $0 | |
| Durable Medical Equipment (DME) - including, but not limited to: rental equipment, supplies, wheelchairs, ventilators, oxygen, monitors, lifts, nebulizers, bili-blankets. | Covered | Prior approval may be required for some equipment. | $0 | |
| Emergency Care (in-network and out-of-network) | Covered | $0 | ||
| Emergency Transportation | Covered | $0 | ||
| Enteral/Parenteral Nutrition Therapy | Covered | If provided via tube and sole source of nutrition. | $0 | |
| Family Planning Services | Covered | Self-referrals; in- and out-of-network providers covered. | $0 | |
| Fluoride Rinse/Varnish | Covered | As a part of EPSDT only. | $0 | |
| Genetic Testing | Covered | Prior approval required. | $0 | |
| Hearing Tests, Aids & Devices | Covered | Ages 20 and younger. | Prior approval required. | $0 |
| Home Health Care | Covered | 50 visits per year (July 1 - June 30). | Prior approval required. | $0 |
| Home Infusion Therapy | Covered | . | Prior approval may be required for certain medications | $0 |
| Hospice Care | Covered by SCDHHS | $0 | ||
| Hysterectomy | Covered | Completed Consent for Sterilization form (Form HHS-687) required. | Prior approval required. | $0 |
| Infertility Services | Not Covered | N/A | N/A | |
| Infusion Centers | Covered | $0 | ||
| Inpatient Behavioral Health Services | Covered | Prior approval required. | $25.00 | |
| Inpatient Medical/Surgical Services | Covered | Prior approval required. | $25.00 | |
| Inpatient Pediatric Rehabilitation Services | Covered | Prior approval required. | $0 | |
| Insulin Pumps | Covered | Prior approval required. | $0 | |
| Laboratory Services | Covered | Prior approval required for some services. | $0 | |
| Long-Term Care Facility | Covered | SCDHHS CLTC certification (Form 181) must be completed prior to admission. | Prior approval required. | $0 |
| Maternity Services | Covered | Prior approval required for some services. | $0 | |
| Newborn Hearing Screening | Covered | Included in the Core Benefits when provided to newborns in an inpatient hospital. | $0 | |
| Non-Emergency Medical Transportation | Covered by SCDHHS | N/A | ||
| Non-Participating Providers | Covered | Must be medically necessary and service not available in-network. | Prior approval required. | Varies |
| OB Ultrasounds | Covered | Maternal-fetal medicine provider: No limitation. All other providers: three ultrasounds per pregnancy. | $0 | |
| Office Visits (PCP/Specialists) (Well & Sick Visits) | Covered | $0 | ||
| Oncology-Related Chemotherapeutic Drugs and Support Services | Covered | Prior approval required. | $3.40 for self-administered drugs only. | |
| Orthopedic and Spinal Surgery | Covered | Prior approval required. | $0 | |
| Orthotics & Prosthetics | Covered | Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. | Prior approval required for some services. | $0 |
| Outpatient Hospital Services (non-emergency) | Covered | Prior approval required for some services. | $3.40 | |
| Outpatient Surgery and Procedures | Covered | Prior approval required for some services. | $3.40 | |
| Pain Management Services | Covered | Prior approval required for some services. | $0 | |
| Podiatry Services | Covered | Prior approval required for some services. | $0 | |
| Power Wheelchairs | Covered | Every seven years, limited accessories covered. | Prior approval required. | $0 |
| Prescriptions and Medications | Covered | Subject to age and quantity limits per Preferred Drug List (PDL). | Prior approval may be required for some medications. | $3.40 $0 copay for select medications on the PDL for asthma, COPD, smoking cessation and diabetes. |
| Pulmonary Rehabilitation Services | Covered | $0 | ||
| Rehabilitative Therapies for Children, Non-Hospital Based | Covered | Ages 20 and younger, combined total of 105 hours (420 units) per year (July 1 through June 30). | Prior approval required. | $0 |
| Reversal of Sterilization | Not Covered | N/A | ||
| Smoking Cessation Products | Covered | Subject to quantity limits per Preferred Drug List (PDL). | $0 copay for smoking cessation medications on PDL. | |
| Sterilization | Covered | Complete Consent for Sterilization form (Form HHS-687) requred. | $0 | |
| Substance Use Disorder Services | Covered | Prior approval required for some services. | $0 | |
| Transplants | Covered | Prior approval required. | $0 | |
| Vaccines/Immunizations (Adult) | Covered | Covered in accordance with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) vaccine recommendations guidelines for adult beneficiaries 19 years of age and older. | $0 | |
| Vaccines/Immunizations (Children) | Covered | Ages 18 and younger. | $0 | |
| Vision - Routine Screening (Children) | Covered | Ages 20 and younger. One pair of glasses every 12 months. One replacement set every 12 months. | $0 | |
| X-Ray/Radiology and Imaging Services | Covered | Prior approval required for some services. | $0 |
*This list is not all inclusive. Please check the Member Handbook and talk to your doctor prior to scheduling services.
If you are enrolled in case management, your case manager can confirm whether a service requires prior authorization.
State Covered Services
Absolute Total Care does not cover all of your services. Some services are covered by Medicaid Fee-for-Service and are called “carved-out benefits.”
State covered services include:
- Routine and emergency dental services – DentaQuest: 1-888-307-6553
- Long-term institutional care for stays over 90 days
- Hospice care
- Transplants (other than corneal transplants)
For a complete list of services provided by either Absolute Total Care or Medicaid Fee-for-Service please contact Member Services at 1-866-433-6041 (TTY: 711).