Referral
Authorization from your primary care doctor to see a specialist, required by some insurance plans.
What is Referral?
A referral is an order or recommendation from your primary care physician to see a specialist. Some insurance plans, particularly HMOs, require referrals before they'll cover specialist visits.
Referrals serve two purposes: they ensure your PCP coordinates your care, and they help insurance companies control costs by preventing unnecessary specialist visits. Without a referral, you might have to pay the full cost of the specialist visit.
PPO and EPO plans typically don't require referrals - you can see any specialist directly. Always check your plan's requirements before scheduling specialist appointments to avoid surprise bills.
Frequently Asked Questions
Do I need a referral with a PPO?
Usually no. PPOs and EPOs typically let you see specialists directly without referrals. HMOs usually require them.
What happens if I see a specialist without a referral?
If your plan requires referrals, you might have to pay the full cost of the visit. The insurance company may deny the claim.
How do I get a referral?
Schedule an appointment with your PCP. Explain your symptoms or concerns, and they'll provide a referral if they agree you need specialist care.
Related Terms
Primary Care Physician (PCP)
Your main doctor who provides routine care and coordinates specialist referrals in HMO plans.
Health Maintenance Organization (HMO)
A health plan that requires you to use in-network providers and get referrals for specialists.
Preferred Provider Organization (PPO)
A health plan that offers flexibility to see any doctor, with lower costs when you use in-network providers.
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