Health Plan of San Joaquin/Mountain Valley Health Plan has a network of over 650 specialists. Specialty care includes allergy, dermatology and obstetrics (prenatal care), and many other types of services.
With a referral from your primary care provider (PCP), you can see a specialist for evaluation, consultation, or care. Some services such as prenatal care, urgent or emergency care, do not require referral.
Referrals
Your PCP handles your care. When you need to see a specialist, your PCP will send a referral. Once the referral is sent, you can plan your appointment. After your visit, the specialist updates your PCP to continue proper care.
Some services you can refer yourself to see a provider that’s in-network.
Self-Referral services:
- OB/GYN care for routine preventative exams.
- Mental Health care to see mental health providers.
- Optometry(eye) care. Medi-Cal members can seek routine eye exams and eyeglasses.
- Acupuncture or Physical Therapy. You can have up to six visits per year. Extra visits may need prior approval.
Sensitive care such as pregnancy related care, sexually transmitted infection (STI) care, and HIV testing or counseling can be done through self-referral.
For those under 18, care for sexual assault, substance use disorder, and mental health may be used without a parent’s consent.
Services that don’t need a referral include:
- Emergency services
- Urgent care
- Routine shots (such as flu shots)
- Kidney dialysis outside the service area
Prior Authorizations (Prior Auth)
Prior auth will confirm a service is medically needed and part of your benefits. Your provider will send a request to your health insurance for approval.
The following services will need prior authorization:
- Non-emergency hospitalizations
- Outpatient surgeries
- Imaging (CT scans, MRIs)
- Specialized care (home health care)
- Out-of-network providers
Authorization Process:
The request is reviewed based on your condition and the documentation shared. If more details are needed, the HPSJ/MVHP team will reach out to your provider.
Most requests can take up to 5 business days. Some requests may be rushed if your health is at risk. You may see a response within 3 days.
If approved, you will be sent notice, and your provider will schedule the service. If denied, a Notice of Action (NOA) letter will be sent to explain the result. You will also see your rights to appeal the notice.
If care was given without prior authorization, the provider can request a review within 90 days to determine coverage.