On the Sana First Health Plan (SFHP), most non-emergency specialist and outside medical care requires an active referral from Sana Care to be covered. However, several key care categories are exempt from referral requirements.
Understanding these exceptions helps you access urgent care quickly without delays.
Referral Exceptions (No Referral Required)
1. Emergency Room (ER) Care
- Referral Required? No.
- How It Works: If you are experiencing a life-threatening medical emergency, call 911 or go directly to the nearest emergency room immediately. Never delay emergency care to seek a referral or contact Sana Care.
- Coverage: Emergency room services are always covered under your standard plan emergency benefits without needing a referral packet or authorization.
2. Urgent Care Centers
- Referral Required? No.
- How It Works: For urgent, non-life-threatening medical issues that arise after hours or when virtual care isn't suitable (such as minor cuts requiring stitches, sprains, or sudden illness), you can visit any urgent care center directly.
- Coverage: Urgent care visits are always covered under your standard plan benefits without needing a referral packet or authorization.
3. OB/GYN
- Referral Required? No.
- How It Works: You can schedule appointments directly with an OB/GYN or reproductive specialist of your choice for routine well-woman exams, prenatal/postpartum care, family planning, or specialist gynecological conditions.
- Coverage: All routine and specialist OB/GYN and reproductive healthcare services are covered under your standard plan benefits without needing a referral packet or authorization.
4. Mental Health Services
- Referral Required? No
- How It Works: You can connect directly with licensed mental health professionals—including therapists, counselors, and psychiatrists—without contacting Sana Care first.
- Coverage: In-person and virtual mental health services are fully exempt from referral requirements, allowing you to access behavioral healthcare directly under your standard plan benefits.
- Important Note: Monthly subscription-based mental health apps or recurring membership platforms are not covered under any Sana plan. Services must be billed as standard medical visits from a licensed provider under your plan's mental health benefits.
5. Pediatric Primary & Preventive Care
- Referral Required? No.
- How It Works: Sana Care does not provide direct pediatric primary care. Children on SFHP continue seeing their regular primary care pediatrician or family medicine doctor for well child checkups, routine vaccinations, sports physicals, and everyday illness visits.
- Coverage: Routine pediatric primary and preventive care visits with your child's doctor always covered under your standard plan benefits without needing a referral packet or authorization.
Care Requiring a Referral
Pediatric Specialist Care
- Referral Required? Yes.
- How It Works: While routine primary care visits with your pediatrician are exempt, seeing a pediatric specialist (such as a pediatric cardiologist, allergist, or dermatologist) does require a Sana referral packet to ensure claim coverage.
How to Get Authorized:
- Have your child's primary care pediatrician evaluate your child and provide a written referral or recommendation.
- Open the Sana App or log in to your member portal, toggle to your child's sub-profile, and message Care Navigation directly.
- Upload a copy of your pediatrician's referral or After Visit Summary. Care Navigation will issue the official referral packet for the specialist.
Not Sure If You Need a Referral?
If you're unsure whether your care requires a referral, contact Sana Care or Care Navigation before scheduling or receiving care. We'll help you understand the right next step.
Have questions? We've got you covered.
- Log in to view account details.
- Search FAQs in our Help Center.
- Connect with Customer Support directly through the chat icon on most Sana pages or call us at (833) 726-2123 Monday through Friday, 7 AM to 7 PM Central.