How Referrals Work With Your HMO

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How Referrals Work With Your Health Insurance

Depending on the type of health insurance plan you have, you may not be able to just go straight to a specialist when you think you need the services they offer. If you have a health maintenance organization (HMO) plan, you’ll probably need to first go to your primary care physician (PCP). If they agree that you need to see a specialist, they’ll refer you to one, and indicate in your medical records that this has been done.

Some health plans require the referral to be in writing directly from the doctor, while others will accept a phone call, email request or online portal request  from your primary care provider (Hospital).

In order to make sure that everything is in order regarding seeing a specialist, you should be proactive, and make sure that your insurer has received and approved a referral before you make an appointment with your specialist. Then you will know that your visit to the specialist will be covered under your healthcare plan.

Referrals for HMO Plans

Heath maintenance organizations require you to consult a primary care physician within the network hospital. The primary care physician is then responsible for managing your health care. The primary care physician is responsible for making recommendations as far as courses of treatment, specialist visits, medications, and more.

The primary care physician/general practitioner  also provides referrals for any other necessary services or specialist visits within the network. These referrals allow you to go see another doctor or a specialist within the health plan’s network. If you do not have a referral from your primary care physician, your HMO likely will not cover the service at all.

But some modern HMOs have relaxed these rules and now allow members to visit specialists within the plan’s network without having a referral from their primary care physician. So you’ll want to check the specific requirements of your plan.

Regardless of whether a referral is required, HMOs generally require members to get all of their care from providers who are in the plan’s network, with out-of-network care only covered in emergency situations.

Prior Authorization

Depending on the service you need, prior authorization from your insurance plan may be necessary in addition to the referral from your PCP. Your PCP might automatically obtain prior authorization as part of the referral process. But as a general rule, you’ll want to double-check with your insurer and the specialist, before you receive treatment, to be sure that prior authorization has been granted if it’s required by the insurer.


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