Prior Authorizations and Referrals
Peach State Health Plan offers health insurance plans with comprehensive healthcare services that suit the needs of families and individuals throughout Georgia.
View some of Peach State Health Plan's benefits below. You can also view more information in our Member Handbook.
As a Georgia health plan option, Peach State Health Plan can help you find a provider, find local resources, plan an appointment and find transportation. Call Member Services at 1-800-704-1484 (TTY/TDD 1-800-255-0056).
Care coordination and disease coaching are part of your health benefits and are provided to you at no cost. Peach State Health Plan pays for these services. We provide services for many conditions, such as asthma, diabetes, COPD, high-risk pregnancy and many more. Call Member Services at 1-800-704-1484 (TTY/TDD 1-800-255-0056).
[Health Plan] is proud to work with SafeLink Wireless to offer you this special, federal program. Apply and receive a smartphone, 350 monthly minutes, 3GB monthly data, unlimited text messages and calls to [Health Plan] Member Services. Some limitations may apply.
How to Enroll:
- Visit SafeLink's website to apply online.
- Call SafeLink at 1-877-631-2550 to apply over the phone.
As a Peach State Health Plan Member, you can choose who you see for your healthcare needs from our network of Providers. We have many for you to choose from. If you need help choosing a doctor, call Member Services at 1-800-704-1484 (TTY/TDD 1-800-255-0056).
Preventative care visits are covered by Peach State Health Plan. This means visiting the doctor for a regular check-up, rather than waiting until you are sick.
Peach State Health Plan covers an annual physical for adults.
Regular child check-ups are also covered for those under the age of 21. These doctor visits should occur at the below ages. Children also need a blood lead test at 12 and 24 months of age. We cover this. After that, if they are high risk, they need the blood lead test each year age 3 to 6.
- Birth or neonatal exam
- 2 to 4 days for newborns discharged less than 48 hours after delivery
- By 1 month
- 2 months
- 4 months
- 6 months
- 9 months
- 12 months
- 15 months
- 18 months
- Once per year from 2 years old through 20 years old
Our Nurse Advice Line is ready to answer your health questions 24 hours a day – every day of the year. It is staffed with Registered Nurses. These nurses have spent lots of time caring for people. Now they are ready and eager to help you. Call 1-800-704-1484 and say "Nurse."
Start Smart for Your Baby (Start Smart) is our special program for women who are pregnant and for those moms who just had a baby. We want to help you take care of yourself and your baby every step of the way. If you are pregnant, please let us know by completing a Notification of Pregnancy form. After completing this form you will be enrolled in Start Smart. You will receive information in mail and over the phone. You can also get information in the Health & Wellness section.
Tips for Pregnancy
If you are pregnant or want to become pregnant, keep these things in mind:
- Go before you show! Go to the doctor as soon as you think you are pregnant. It is important for you and your baby to see a doctor as early as possible. It will keep both of you healthy. It will also help your baby get off to a good start. It is even better to see a doctor before you are pregnant. This is so you can get your body ready for pregnancy.
- Maintain healthy lifestyle habits. This includes exercising, eating balanced and healthy meals, and resting for 8-10 hours every night.
- Do not use tobacco, alcohol or drugs now or while you’re pregnant.
Breastfeeding
Doctors and health organizations agree that breastfeeding is best. You may already know that breast milk is packed with the perfect mix of nutrients your baby needs. Did you know that it is also more than just food? Breast milk has special ingredients, like antibodies, that only you can provide. Breast pumps are helpful if you are breastfeeding and have to be away from your baby. Call us after you deliver to see if breast pumps are offered.
Are You Pregnant? Tell Us Right Away!
Call us. Or, you can login to your Peach State Health Plan account and fill out the Notification of Pregnancy form.
Interpreter services are provided free of charge to you during any service or grievance process. This includes American Sign Language and real-time oral interpretation.
If you need something translated into a language other than English, please call Peach State Health Plan. We can also provide things in other formats such as Braille, CD or large print.
If you need an interpreter for your medical appointment, contact Peach State Health Plan Monday through Friday from 7:00 a.m. to 7:00 p.m. Eastern Time before your appointment. We will arrange for one to be at your appointment.
Peach State Health Plan provides the same benefits as Medicaid and PeachCare for Kids®, plus more. In this section, you can learn about the health benefits, pharmacy services and value added services Peach State Health Plan offers.
Need help understanding these benefits and services? Call us at 1-800-704-1484 (TTY/TDD 1-800-255-0056).
You can also view more information about Peach State Health Plan in our Member Handbook.
All services must be medically necessary. Your Primary Care Provider will work with you to make sure you get the services you need. These services must be given by your Primary Care Provider or by another provider that your Primary Care Provider refers you to.
Some services may:
- Have coverage limits.
- Need a doctor’s order.
- Need prior approval.
*Some Medicaid and PeachCare for Kids® members may not have all the benefits listed.
PRIOR AUTHORIZATION
Peach State Health Plan must approve some treatments and services before our members can receive the service. The provider performing the treatment or service will submit a request for authorization to the health plan along with medical information that supports the treatment. Peach State Health Plan licensed and trained staff members review all prior authorizations and pre-certifications.
Be sure to receive the services listed below from a Peach State Health Plan provider. Services from a provider who is not in the Peach State Health Plan network must be approved ahead of time. This does not apply to emergency services or family planning services.
Some covered services or medications may need approval from Peach State Health Plan, and this is called a Prior Authorization. You do not need a paper referral from Peach State Health Plan to see a provider, but your provider may need to request a prior authorization from Peach State Health Plan for a service to be approved.
Below is a list of services that require prior authorization from Peach State Health Plan before your healthcare provider can proceed with treatment.
- Nursing facility services.
- Home healthcare.
- Hospice care (care for terminally ill). For example, cancer patients.
- Inpatient hospitalization.
- In-patient hospital services. Hospital care is arranged by your primary care provider (PCP) except in the case of an emergency. In-patient hospital care is provided at one of the hospitals associated with Peach State Health Plan. These hospitals are listed in your Provider Directory.
- Partial hospitalization.
- Residential Care for behavioral health.
- Medical supplies. Some diabetic supplies for insulin and blood glucose monitoring do not require authorization.
- Durable Medical Equipment.
- Speech and hearing services. Including hearing aids.
- Physical and occupational therapy.
- Non-routine dental care. For example, surgery.
- Non-routine vision (optical) services. For example, surgery.
- Non-emergency ambulance transportation.
- Plastic and reconstructive surgery.
- Certain diagnostics tests. For example. MRI/MRA, PET scans.
- Sleep Studies. (Exception: No Prior Approval required when Sleep Study is performed in the home)
- Transplant procedures and related services, regardless of age.
- Chemotherapy.
- Radiation cancer treatment.