My Coverage Explained

How HMO Works -- The Referral Process

Did you know that with an HMO, unless it is an emergency, using a doctor or hospital that is not in your network will make you responsible for the full cost of the care provided?

Referrals are an important piece of saving money with your HMO coverage. If you have an HMO plan, you should know when you need a referral.

If you have an HMO  or are thinking of purchasing an HMO, this information can help you learn
when you need a referral and who should be giving you one.

When you Need a ReferralSpecialist visits require a written referral from your PCP. HMO plans cover some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist.

What is a doctor referral?
A referral is authorization or permission from your Primary Care Physician (PCP) or Women's Principal Health Care Provider (WPHCP) to receive care from a specialist, or a doctor who treats specific conditions. Special treatment includes health care services from a specialist, hospital, or urgent care facility that cannot be provided by your PCP or WPHCP. You may also need a referral for things like lab work or physical therapy.

To keep costs down, make sure all your health care services are either performed by or authorized by your PCP or WPHCP, and you use Provider Finder® to find a specialist in your network.

What is the PCP/WPHCP responsible for in the referral process?
The PCP/WPHCP will:

  • refer you to an in-network medical specialist  
  • monitor the care received from the specialist
  • authorize additional care that is beyond the first referral
  • issue referrals for lab work or physical therapy

I have an HMO. How do I get a referral?
Before receiving health care services from a specialist you should:

  • Select a Primary Care Physician who is a part of the medical group you selected. Women must select a Women's Principal Health Care Provider who is affiliated with the selected medical group.
  • Visit your PCP/WPHCP to address your health care needs.

Once your PCP/WPHCP has determined that you require care from a specialist, they will complete the referral to the specialist and send the referral to the medical group for authorization.

The specialist will only provide the services authorized by the referral. If you need more services not included in the referral you’ll need another referral from your PCP/WPHCP.

If you are receiving ongoing treatment, you should check with your PCP/WPHCP to see if you can instead get a "standing referral". Your standing referral from your PCP will allow you to see your specialist without needing a new referral for each visit.

Get more information about your health plan at any time! Not all benefits are offered by all health plans. To see the limitations and exclusions in your plan, please refer to your benefit materials or log in or register for your member account, Blue Access for MembersSM. Visit the My Coverage tab to verify your coverage and identify your medical group and PCP.

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.

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