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A non-government resource, powered by health insurance experts.
A non-government resource,
powered by health insurance experts.

Q: How Does a Doctor’s Referral Work?

Asked by Anonymous on October 11, 2017

Hal Levy October 11, 2017

Your doctor referral rules will depend on your specific plan. Doctor referrals will be based on the type of network your plan uses.

You’ll have a better understanding of the referral process – including whether you need a doctor’s referral – after you’ve gotten your first referral. Doctor’s referrals are often provided by your primary care physician.

If you’re staying in-network, you can generally take your doctor’s referral to any medical professional that’s willing to treat you. If you’re hospitalized, referrals to different departments in the hospital will be managed by the hospital.

You’ll generally need a doctor’s referral for specialized tests. For instance, you can’t order an x-ray on your own.

However, whether or not you’ll need a referral to see a certain doctor primarily depends on the type of network that your plan uses.

HMO or POS Network: You’ll probably need a doctor’s referral if you have one of these plans. These plans are based around the need to check in with a primary care physician (PCP) before you access specialized services.

PPO or EPO Network: You probably won’t need a referral for most specialists in a PPO or EPO, as long as you visit an in-network doctor.

Original Medicare (Part A+B): With Original Medicare, you can generally see any doctor you like, as long as they accept Medicare.

Medicare Advantage (“Part C”): Since Medicare Advantage operates more like traditional insurance than Original Medicare, you can’t see just any Medicare doctor. Some Part C plans are structured as HMOs, where you’ll need to check in with your primary care physician to get a specialist referral. Other plans are PPOs, where you won’t need a referral for in-network care.

Self-pay: You’re free to pay a medical professional on your own if you’d like to see them without a referral. You may need to sign a waiver stating that you accept full responsibility for the cost of your visit. Although the main use of referrals is for your doctor to bill your insurance, you may need a doctor to write you a referral for services that you can’t order on your own.

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

Many specialists won’t even see you without a doctor’s referral unless you’re willing to pay up front.

You can plan ahead by scheduling appointments with your primary care doctor and the specialist you’d like to be referred to before you receive a referral.

How Long Does My Referral Last For?

You’ll want to ask your doctor how many visits their referral will last for. Note that your doctor may write a referral for longer than your insurance company will accept. You may receive a follow-up letter from your insurance company confirming the details of your referral.

You can get multiple referrals to the same doctor once the original referral expires.

Getting Help with Referrals

Since each plan is different, you can call your insurance provider to learn about your plan’s referral procedure. You can also look at your plan’s manual online, or request a paper copy. Medical offices may be able to help you navigate your insurer’s procedures, but they might not have specific information about your plan.

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