What is a referral for health insurance?
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UPDATED: Mar 19, 2020
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- A referral is an order of pre-approval from your primary doctor to see a specialist or receive a particular service
- Referrals are usually required by HMO plans
- Most plans require a written order, but some may accept a phone call or other form of communication from your primary care provider
- It is important to get a referral prior to receiving the services or seeing a specialist otherwise your insurance company may not pay for the services
A referral is an order from your primary care provider pre-authorizing a visit to a specialist, usually one within the same network. These are typically required by HMO plans.
For the most part, it is necessary for these referrals to be written orders. However, some plans and specialists will accept a phone call from the primary care physician. If you do not get the referral from your primary medical provider prior to receiving the service, there is no guarantee that your health insurance will cover it and you ma be responsible for paying the cost.
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Do I need a referral if I have an HMO plan?
Referrals are typically necessary when you have an HMO plan. HMO plans require you to select a primary care provider who is responsible for the management of many of your healthcare decisions. If you need to see a specialist, such as a cardiologist or orthopedic doctor, you will your primary care doctor to recommend this course of action and refer you to a specialist within your plan’s network.
If you have an HMO plan, any doctor that you see must be in your network or the visit will not be covered.You will typically only be responsible for paying your co-payments with an HMO plan, as long as you see providers within network.
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What is an HMO plan?
HMO stands for health maintenance organization. It is a plan that requires you to pick one primary care provider(PCP) and see only providers within your network. Although this can limit the flexibility in which health care providers you see, HMO’s often offer the best prices. An HMO can work well for you and your dependents if you already know what services you need and that they will be within your network.
Do I need a referral if I have a PPO plan?
You typically will not need a referral if you have a PPO plan. You also will have a wider variety of providers to choose from and they do not necessarily need to be within your network. You do not have to choose a primary care provider who is responsible for managing a lot of your healthcare decisions.
With most PPOs, you will only be expected to pay your copayments. However, some PPO networks have annual deductibles that need to be met in order to pay for your services.
Additionally, if you see an out of network provider when you have a PPO plan, you are expected to first pay for the service, but your PPO provider may reimburse you for the visit.
What is a PPO plan?
PPO stands for preferred provider organization. Although it is unlike you will need a referral to see a specialist, it is possible you may need one for an expensive service or test. PPOs provide more flexibility for you because you can see physicians outside of the network, although it may wind up being more expensive for you.
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