How do referrals work in my HMO plan?
Who is this for?
If you are a Blue Care Network (HMO) member, this information can help you learn how referrals work if you need to see a specialist for treatment.
If your health insurance plan is an HMO, or health maintenance organization, you probably know that your primary care physician coordinates all your health care services. Your doctor keeps track of all your medical records and provides routine care.
But what if you need to see a specialist? In that case, you’ll need a referral from your primary care physician before you can see any other health care professional (except in an emergency). If you don’t get a referral first, your insurance won’t cover the cost of your care.
For example, if you get a skin rash, you wouldn’t go straight to a dermatologist. You would first go to your primary care physician, who‘d examine you. If your primary care physician can’t help you, he or she will give you a referral to a trusted dermatologist in your network who will.
- One exception to this is that women don’t need a referral to see an OB/GYN in their network for routine services such as Pap tests, annual well-woman visits and obstetrical care. You can read more about our Woman's Choice program for details.
How referrals work
A referral from your primary care physician can cover a period from 90 to 365 days. Referrals for three chronic conditions, oncology, rheumatology and renal management, are issued for 365 days.
Your primary care physician will let you know when your referral is approved or Blue Care Network will send you a letter in the mail.
Once you get your referral, your specialist can order any medically necessary treatment for you until the referral expires. If your specialist recommends that you see another specialist, you’ll need to coordinate a new referral with your primary care physician for that care.
Some services need prior approval
Blue Care Network needs to review and approve some health care services before you receive them. Those services include, but are not limited to:
- Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen
- Physical therapy, speech therapy and occupational therapy
- Weight-reduction procedures
- Bone marrow transplants
- Infertility services
- Breast reduction
- Durable medical equipment
- Services from out-of-network physicians or health care professionals
- Procedures that may be experimental or investigational
Since your primary care physician coordinates all of your health care needs, you’ll need to check with your doctor before you see any doctor or health care professional from outside your network.
Without a referral from your primary care physician, you’ll have to pay for all the costs of out-of-network treatment unless it’s approved by Blue Care Network or it’s an emergency.
If you change doctors
If you change your primary care physican while a specialist is treating you, you’ll have to get another referral from your new primary care physician. Your specialist care may not be covered by your insurance until you get that new referral.
Contact us if there's a problem
If for any reason you have problems with your referral, please call us so we can help you straighten things out.