Health maintenance organization (HMO) plans may require a referral from a primary care physician prior to you obtaining services for specialty care. As a patient, you are responsible for securing referrals from your primary physician prior to making an appointment to see a specialist.
If you arrive for a specialist's appointment with no referral, you may be asked to:
- Contact the primary care physician to obtain the referral.
- Reschedule your appointment.
- Pay the estimated cost of the service prior to seeing the physician.
HMO insurance plans also require that testing, such as laboratory work, X-rays and physical/occupational therapy, be completed at specific sites. As the patient, it is your responsibility to know which site you must use for tests and services. You may obtain this information through your primary care physician’s office or your health insurance company’s member services department.
Point of Service and Preferred Provider plans usually offer a network of physicians and hospitals that the member must select from when receiving health care. Members receive maximum benefits if they choose in-network providers. Members may also choose to “self-refer” to an Out of Network provider, but a higher co-payment may be applied and the plan may require higher deductibles and/or co-insurance amounts. If you choose to use these options, be aware that your financial responsibility for co-pays and/or co-insurance may be significantly higher.
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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.