Doctor Referrals

Does Medicare require doctor referrals?

Some health plans require referrals to see a specialist. Here are the basics.

Medicare Advantage HMO (Health Maintenance Organization) plans commonly require doctor referrals. If you are on this type of plan, you may need a referral from your primary care physician (PCP) in order for you to see a specialist. The referral system is in place so that your PCP can coordinate your medical care.

Medicare Advantage plans, usually HMOs, are the only type of Medicare plan that will require a referral. Check your plan benefits to confirm if a referral is required for your situation. PPO (Preferred Provider Organization) plans typically do not require a referral.

Original Medicare does not require referrals. If you are on a Medicare Supplement, Original Medicare is considered your primary insurance and will be billed first. This means that you do not need a referral to see a specialist.

What is a referral?

A referral is an electronic form that your family doctor (also known as your primary care physician or PCP) sends to your insurance company. It gives you permission to see specialists for a specific amount of time.

How do you get a referral?

To get a referral, you must contact your PCP’s office. Your PCP will send the electronic referral to your insurance company for the specialist you want to see. The doctor must file the referral with the insurance company in order for the specialist visit to be covered

How long does the referral last?

The doctor can choose how long the referral lasts. It is common for referrals to last up to a year. After the specified period of time is up, the doctor must renew the referral.

What happens if you see a specialist without a referral?

If you do not obtain the necessary referral, your insurance may not cover your specialist visit. This means you may have to pay the full cost of the visit.

If you are a RetireMed client and unsure about your plan’s requirements, please call us at 877.222.1942.

If you are not a RetireMed client and have questions about how we can help you, schedule a call with one of our advisors to get started on your Medicare journey.