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Health Insurance Referrals & Specialists | How Your Plan Works

Lewis Mark Published: March 12, 2019 Updated: March 12, 2019

Specialist doctor with patient

For most medical situations, your primary care provider will be able to handle your healthcare needs. There are, however, times when you will need to seek out a specialist, which may require a referral.

Referrals are a pre-approval that are given to individual health plan members, especially those who have HMO or POS plans, which allows them to see a specialist, or a doctor within the same network, while still having it covered by the insurance company. Learn when and why you’ll need a referral, and if your plan requires it.

What Is An Insurance Referral?

If your doctor believes that your care would be best handled by a specialist, they may want you to see one. Take, for example, an ophthalmologist. If you are having issues with your eyes, your primary care physician may not be able to treat the situation properly. That is when your doctor would want you to see a specialist.

Getting the paperwork done properly ensures that when you see the specialist, your insurance provider will pay the cost for the visit. While there may still be copays and/or other fees you might be responsible for, the majority of the visit is usually covered. It’s basically a way for the insurance company to know, without a doubt, that your physician wants you to see the specialist.

How Your Insurance Referral Works

If you need to see a specialist or another doctor, you may need a referral to see a specialist. Your physician will contact your insurance company and explain who you need to see, and more importantly, why. It is then up to your insurance company to state whether or not they will provide coverage for the specialist visit

How Long It Normally Takes

The big question most patients have is to wonder how long the process will take. In all honesty, that depends on the specialist, or physician, you are being referred to see. The referral from your primary care physician may be sent out within a few hours but if the specialist office is a busy one, the full process may take a while to be complete.

Can You Go To A Specialist Without A Referral?

Yes, it is possible to make an appointment to see a specialist without having to go through an insurance referral. The difference is, however, that without a referral to see a specialist you may be required to pay the full amount of the visit. There are even some physicians who refused to see new patients unless they have been referred from the primary care physician.

With Your HMO Plan

Most HMO (health maintenance organization) plans require that you choose a primary care physician to care for your health needs. an HMO plan also usually requires that you get an insurance referral in order to see a specialist or somebody outside of the pre-approved plan. Generally, with an HMO, if you are going outside of the network where there is no coverage you will often have to pay the entire cost of any medical services that you undergo.

With Your PPO Plan

A PPO (preferred provider organizations) plan tends to provide a bit more flexibility when it comes to choosing a healthcare provider. With your PPO plan, you can often see any doctor, or specialist, without having to see your primary care provider first. This means that you will often not need a referral from your primary care physician in order to see a specialist or a different doctor.

While a PPO sounds amazing in many aspects, it is important to keep in mind that the premiums tend to be higher for a PPO and that it is very common for there to be a deductible that you must pay for any doctor or specialist visit you go to.

With Your EPO Plan

An EPO (exclusive provider organizations) plan is actually a lot like an HMO plan. In general, most EPO plans do not pay for any care that is received outside of the Provider Network. Members with an EPO plan, however, may be able to see a specialist without their physician’s recommendation required.

Insurance Vs. Provider

It’s important to know the difference between the two different types of referrals that you may receive. When a provider recommends that you go to see another physician or a specialist, that is considered to be a provider referral. Once the insurance has stated that they will cover the cost of care, that is an insurance referral.

What To Do If You Can’t Get A Referral

If your physician or insurance provider doesn’t want to give you the paperwork you need to see the specialist, don’t panic. First, contact your doctor again and confirm that they want you to see a specialist. If they do, explain to the doctor your issues with your insurance company. Generally, physicians know how to work with insurance companies to provide the best care for their patients.