Skip to Main Content

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

Absolute Total Care does require member copayments/cost-sharing for certain covered and approved medically necessary medical services before July 1, 2024.

Effective July 1, 2024, Absolute Total Care no longer requires a copay for any service.

The following Medicaid beneficiaries do not have to make copayments before July 1, 2024:

  • Children under 19 years old
  • Pregnant women 
  • Institutionalized individuals (such as a nursing facility) 
  • 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*

Services Covered and Not Covered by Absolute Total Care may be found in the latest Member Handbook on the Member Handbooks and Forms page.

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

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).