How Do Referrals Work in My HMO Plan?

When you have an HMO plan, a primary care physician, or PCP, is your first point of contact for care. If your PCP can’t provide the care you need, he or she will give you the name of a doctor who can. That’s called getting a referral. 

In some cases, HMO plans won’t help pay for care you get from doctors without a referral. You can avoid unexpected bills by understanding how referrals work.

The referral process

Here’s an example of how referrals work. You’ve had a runny nose, congestion and itchy eyes for a few weeks. Is it a cold? Is it allergies?

When you have an HMO plan, you go to your PCP first to find out. After an exam, she rules out a cold and suspects it may be an allergy. She refers you to an allergist. The referral may be electronic, on paper or called in.

Getting a referral doesn’t guarantee your plan will cover or help pay for everything. For example, you may have a copay, need to meet your deductible, or pay for things your plan doesn’t cover.

But without a referral, you could pay more or all of the costs.

Important information about referrals

Referrals need to come from your current PCP if you want your plan to cover or help pay for your care when:

  • A specialist refers you to another specialist
  • You’re going to see a specialist who’s not in your plan’s network 
  • You were seeing a specialist before enrolling in an HMO plan and you want to continue seeing that specialist
  • You change your PCP while getting care from a specialist; your new PCP may need to issue a new referral

Some other things you should know about referrals:

  • Referrals expire. You’ll have anywhere from 90 days to one year to see the doctor you were referred to, depending on the specialty
  • If we send you a letter related to a referral, you can find a copy of it in your member account

When you don’t need a referral

Your plan helps pay for these services without a referral:

  • Medically necessary emergency treatment and urgent care
  • Routine care from an obstetrician-gynecologist who takes your plan, including preventive services like mammograms and Pap smears
  • Behavioral health services when you go to a provider who takes your plan
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