How Does a Doctor’s Referral Work?

Will you need a referral to see a specialist or have a specific test? Your doctor’s office will be able to tell you what your network coverage is and how they handle referrals.

A doctor’s referral typically comes from the patient’s primary care physician. To better understand what you need to do next, contact your insurance company or call your PCP.

If your care is coordinated within the hospital’s network, you can visit any healthcare professional or department as long as it’s related to your doctor’s referral.

Some tests require a doctor’s referral, such as an x-ray exam. What generally determines whether or not you need one is what type of managed care network your health insurance uses.

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HMO or POS Network

If you have one of the following types of plans, you will likely need a doctor’s referral. These plans are based on an individual’s requirement after checking with their primary care physician (PCP) before accessing specialized services

PPO or EPO Network

You may not need a referral from your primary care physician if you have an HMO or PPO plan. But using specialists that are included in your insurance’s network will help keep the expenses affordable.

Original Medicare (Part A+B)

Medicare coverage is minimal with Original Medicare with no referral required but requires a doctor’s referral for Part A and Part B.

Medicare Advantage (“Part C”)

The advantage of Medicare works differently from Original Medicare. So you can only see doctors that are part of your plan’s network. Some Part C plans work as HMOs, which means you’ll need to get a referral from your primary care doctor in order to see a specialist.

Other plans are PPOs, where you won’t need a referral for in-network or out-of-network care. However, if you see a provider outside of your network, you will be responsible for paying that provider. And if your plan is private fee-for-service (PFFS), also known as self-insured, you’ll need a referral for every visit.

Self-pay

You don’t need a referral to see doctors off of their lists. You may find that you sign a waiver stating you are willing to take responsibility for the entire cost of your visit. But be aware that this does not guarantee coverage by your insurance company if someone else makes an appointment on your behalf and has you listed as their dependent.

If you’re paying out of pocket for Medicare, there are many benefits to having a doctor’s referral. For one thing, if your plan is an HMO and needs referrals, it will be much easier to see the specialists who can’t take self-pay without them. Plus, since most plans require referrals to get approval for out-of-network care, this is a way to avoid those extra steps.

What If I Don’t Have a Referral When I Go to the doctor?

Many specialists won’t see you without a doctor’s referral unless you’re willing to pay for their services upfront. Setting up an appointment with your primary care physician in advance to get the referral first thing can solve this.

For How Long Does My Referral Last?

When your primary care physician refers to visit a specialist, your doctor will tell you how many times that referral covers. Your doctor can also receive referrals for visits or services not covered under your individual plan. Approximately 80% of plans require prior authorization even if your doctor approves the service. So remember to check whether there’s any additional paperwork before attending an appointment.

If a primary care physician refers you to a doctor, your insurance company may send you a letter confirming the referral and authorizing treatment details. You can get referrals to the same physician once your original authorization expires.

Getting Help with Referrals

Depending on your plan, there may be a referral procedure that requires doctors to validate the need for medical care. Be sure to check if you have coverage for medical procedures or treatments before scheduling an appointment with your doctor. Calling your insurance provider, reviewing your package materials (online or via paper copy), or consulting with hospital programs would help you determine which requirement it is and when a referral is needed.

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