How do referrals work in my HMO plan?
Who is this for?
If you're a Blue Care Network 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? For most, but not all, HMO plans you’ll need a referral from your primary care physician before you can see any other health care professional (except in an emergency). If your plan requires a referral and you don’t get one first, your insurance won’t cover the cost to see the specialist.
For example, if you get a skin rash, you shouldn’t go straight to a dermatologist. You should go to your primary care physician first for an exam. If your primary care physician can’t help you, he or she will give you a referral to a trusted dermatologist in your network.
- An 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.
- You don't need a referral for behavioral health services, either.
How referrals work
A referral from your primary care physician can cover a period from 90 days to one year. Referrals for oncology, rheumatology and renal management are issued for one year.
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 Blue Care Network plans let you self-refer, which means you can see any doctor you want without a referral from your primary care physician. Your costs could be higher, though.
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
For most Blue Care Network plans, 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 physician 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 a 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.