Seeing a Specialist

You should speak about your health care needs with your primary care provider (PCP). But, you do not need to get a PCP referral to see a specialist in the AmeriHealth Caritas Delaware network.

What is a specialist?

Your PCP can treat most health problems. However, there may be times when you need to see a specialist. A specialist is a doctor trained to treat certain health problems.

Specialists can include:

  • Heart doctors (cardiologists).
  • Skin doctors (dermatologists).
  • Doctors for women’s health (gynecologists).
  • Doctors for pregnant women (obstetricians).
  • Doctors for blood problems (hematologists).
  • Foot doctors (podiatrists).
  • Eye doctors (ophthalmologists).
  • Cancer doctors (oncologists).
  • Behavioral health doctors (psychiatrists).
  • Surgeons.

How to get care from a specialist

You can find specialists in our network by using Find a provider. You do not need a referral to see a specialist in our network. A specialist may think you need surgery or other treatment. You can ask to see another specialist. This is called a “second opinion.”

If you want a second opinion, ask your PCP to help you find another specialist in our network. If there is not a network participating provider available, a second opinion from a health provider outside of the network can be obtained, at no cost to you. Prior authorization is required for out-of-network referrals. There is no limit to how many times you may see the specialist.

Out-of-network providers

You need prior approval to see providers who are not in our network. Your doctor will help you get approval.

Sometimes, we may not have a provider who can treat your health problem. You can ask to see a provider who is not in our network. Talk to your PCP about out-of-network providers.

If you are dually eligible for Medicaid and Medicare and receive an order from an out-of-network Medicare provider for services we cover, but Medicare doesn’t, you must use a provider who is in the network.

If you have questions about out-of-network providers, call AmeriHealth Caritas Delaware Member Services, 24 hours a day, seven days a week, at:

  • Diamond State Health Plan: 1-844-211-0966 (TTY 1-855-349-6281).
  • Diamond State Health Plan-Plus: 1-855-777-6617 (TTY 1-855-362-5769).
Members