Do You Need a Referral to See a Specialist? Medicare, HMO and PPO Rules

What a referral is

HealthCare.gov's glossary defines a referral as a written order from your primary care doctor for you to see a specialist or get certain medical services. It adds that in many Health Maintenance Organizations (HMOs) you need a referral before you can get care from anyone except your primary care doctor, and that if you do not get one first, the plan may not pay for the services.

A referral is a coverage rule. A specialist may be happy to see you without one, but if your plan requires a referral and you skip it, you may be left with the bill. Some specialists also ask for a referral letter or records from your primary care clinician so they know why you are coming, even when your plan does not require it.

Original Medicare

Medicare.gov's comparison of Original Medicare and Medicare Advantage says that with Original Medicare you can use any doctor or hospital that takes Medicare, anywhere in the U.S., and that in most cases you do not need a referral to see a specialist. In most cases you also do not need prior authorization.

You can call a specialist's office and book directly. Two things are still worth checking: whether the specialist accepts Medicare assignment, which affects what you pay (see our assignment guide), and whether the office wants records or a note from your primary care clinician before the first visit.

Medicare Advantage plans

The same comparison says that with Medicare Advantage you may need to get a referral to see a specialist. The rules depend on the plan type.

HMO plans

Medicare.gov's HMO page says that in most HMOs you need to choose a primary care doctor, and in most cases you have to get a referral to see a specialist. Certain services, like yearly mammogram screenings, do not require a referral. You generally must use doctors and hospitals in the plan's network, except for emergency care, out-of-area urgent care and temporary out-of-area dialysis, and if you get care outside the network you may have to pay the full cost. The page also reminds members to follow plan rules such as getting prior approval for a service when the plan requires it.

PPO plans

Medicare.gov's PPO page says that in a PPO you do not need to choose a primary care doctor and do not need a referral to see a specialist. You pay less when you use providers in the plan's network and usually pay more out of network. Before seeing an out-of-network provider, the page advises contacting the plan to make sure the services are medically necessary and covered.

Other plan types

Other Medicare Advantage plan types have their own rules, and your plan's member materials explain whether and when you need a referral. If you are choosing a plan for next year, our guide to how Medicare choices affect your doctors explains networks and enrollment periods.

Job-based, Marketplace and individual coverage

Commercial plans set their own referral rules, and the plan type is a good first clue. HealthCare.gov's glossary describes point-of-service (POS) plans as requiring a referral from your primary care doctor to see a specialist, HMOs as usually limiting coverage to doctors who work for or contract with the HMO, and PPOs as letting you use providers outside the network for an additional cost. Federal law adds a few protections that apply to many group health plans and individual health insurance. The regulation at 45 CFR 147.138 sets out three that matter for referrals:

• Choice of primary care provider: if the plan requires or allows you to designate a primary care provider, it must let you choose any participating primary care provider who is available to accept you.
• A pediatrician for a child: if the plan requires or allows you to designate a primary care provider for a child, it must let you choose an in-network physician who specializes in pediatrics.
• Direct access to OB-GYN care: covered plans may not require authorization or a referral, including from a primary care provider, for obstetrical or gynecological care from a participating health care professional who specializes in obstetrics or gynecology.

The same regulation also covers emergency services. Not every plan is subject to these rules, so the plan's documents are the final word for your coverage. HealthCare.gov's glossary notes that a primary care provider can be a physician (MD or DO), a nurse practitioner, a clinical nurse specialist or a physician assistant, as allowed under state law.

How to ask for a referral

If your plan requires a referral, the request usually goes through your primary care clinician's office:

1. Book a visit or send a portal message to your primary care clinician explaining the problem.
2. Ask for a specific specialist if you have one in mind, and check that the specialist is in your plan's network. If you do not, ask who they recommend in network.
3. Ask what the referral covers: how many visits, for how long, and whether tests or procedures the specialist orders need separate approval.
4. Confirm the referral is on file with the plan and the specialist's office before your appointment. Bring the referral number if the plan issued one.
5. Track the expiry date. If you need more visits than the referral allows, ask your primary care office to renew it before it runs out.

AHRQ's tips for patients suggest writing down your questions before the visit and asking for written instructions about next steps, which helps when a referral leads to new tests.

If the referral is denied

Ask the office or plan for the reason and what other options you have. For job-based and individual coverage, HealthCare.gov's page on appealing a health plan decision says insurers have to tell you why they denied a claim and how to dispute it, and describes an internal appeal and an external review by an independent third party. Medicare Advantage plans have their own appeal process, described in the plan's member materials. For Original Medicare, Medicare.gov's page on second surgical opinions says Part B covers a second opinion in some cases before medically necessary surgery that is not an emergency, and a third opinion if the first two differ.

Direct access to other professionals

Some kinds of care may be available without a referral depending on your plan and state law, for example visits to certain therapists or eye care professionals. State practice laws and plan rules both apply, and they vary. Before booking, ask your plan whether the visit is covered without a referral and ask the office whether it can see you without a physician's order.

Emergencies and urgent care

A referral is never a reason to delay emergency care. If you think you have a medical emergency, call 911 or go to the nearest emergency department. Medicare.gov's HMO page lists emergency care and out-of-area urgent care among the services covered outside the network. For non-emergency problems after hours, ask your primary care office whether it has an on-call line or video visits; our telehealth guide covers what Medicare pays for video visits.

Finding the right specialist

Once you know whether you need a referral, you can look for a specialist. On this site you can browse clinicians by city and specialty or search by name. Each profile shows the clinician's registered specialty codes, practice address and a link to the state licensing board, and, where CMS lists it, whether they accept Medicare assignment. We do not have plan network or referral data, so confirm network status with your plan. Our specialist checklist covers the rest of what to check.