What is a referral?

A referral is a written order from your primary care doctor for you to see a specialist or to get certain medical services. The method of obtaining a referral depends on the type of insurance plan in which you are enrolled. Typically, your primary care physician provides referrals for care. It is important to note that if your plan requires a referral, you need to get the referral first. If you fail to obtain a referral, or do not obtain the referral prior to being evaluated by a physician or receiving medical services, then the plan may not pay for the services. It is important to note that for emergency and urgent care a referral is not needed. Additionally, if a Medicare Advantage plan is contracted with Medicare then the plan must cover all of the services that original Medicare covers except hospice care and some care in qualifying clinical research studies.

Do I need a referral with a Medicare Advantage PPO?

A PPO (Preferred Provider Organization) is health plan that has contracts with a network of providers, or “preferred providers”, that you may choose to receive treatment or medical services. A PPO does not require that you have a primary care physician and, therefore, you do not need to obtain referrals for treatment or medical services. However, it is highly recommended that you choose a physician or network provider or medical facility that is in the network to avoid paying a higher copay or co-insurance. Additionally, if you go to a physician that is out of the network you will need to pay for the services directly and then file a claim with your plan to get any type of reimbursement. There are situations, however, where you may need to see a specialist and there is not a specialist in the network and/or within reasonable traveling distance. If you encounter this type of situation you should contact your plan administrator, or your agent/benefit specialist, to get assistance in obtaining a referral, or permission, to be evaluated by a physician that is not a part of the plan’s network. This is rarely an issue and your plan administrator or agent/benefit specialist will assist you.

Do I need a referral with a Medicare Advantage HMO?

If you are enrolled in a HMO (Health Maintenance Organization) you will need to receive most, if not all, of your health care from a network provider. You will need to select a primary care physician (also known as “PCP”) that is in the plan’s network. Your primary care physician will be responsible for managing and coordinating all of your health care. If you need care from a physician other than your primary care physician, such as a specialist, your primary care physician will coordinate the referral. The referral should be to a physician that is also a part of the plan’s network. The same can be said if you need diagnostic testing such as blood work, x-rays, MRIs, etc. Your primary care physician will have to provide you with the referral to a medical facility that is a part of the plan’s network. If you do not have a referral, or you go to a physician or medical facility that is not a part of the plan’s network, you will most likely have to pay for all, or most of the cost of the care you receive.

 

Medicare Pathways, Inc.

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