Specialty Care Referrals
Most specialty care requires a referral from your Primary Care Physician.
Referral process:
1. Visit your PCP.
2. Your PCP submits a referral if specialty care is needed.
3. After approval, schedule your specialist visit.
Standing Referrals
For chronic or ongoing conditions, your PCP may request a standing referral for multiple specialist visits.
Out‑of‑Network Referrals
If no appropriate in‑network specialist is available, Balance may approve an out‑of‑network referral at in‑network cost‑sharing.
Check Referral Status
You can check referral status through your member portal or by contacting Member Services.
Behavioral Health Services
Balance covers mental health and substance use disorder services, including:
- Outpatient therapy and counseling
- Inpatient behavioral health treatment (when medically necessary)
Some services may require a referral or prior authorization.
Crisis Support
For immediate help, call or text 988 (24/7 Suicide & Crisis Lifeline).
Hospital Services
Contracted Hospitals
Hospital care must be provided at a Balance‑contracted hospital, except in emergencies. If services are not available at Chinese Hospital or another nearby contracted facility, Balance will authorize care at another contracted hospital at the same cost‑sharing.
Prior Authorization Requirements
- Hospital admissions
- Non‑emergency hospital services
Your provider will submit authorization requests.
Emergency Care
Emergency services do not require prior authorization. In an emergency, go to the nearest emergency room.
Need Assistance?
Visit your member portal or contact Member Services for help with referrals, authorizations, or finding care.
