How HMO Works: The Referral Process

When you sign up for an HMO, your first step is to pick a primary care provider (PCP) to manage your care. 

Your PCP will make sure you get the care you need, even when you see another doctor or go to the hospital. When you have a health issue, you’ll first go to your PCP. If the PCP thinks you need to see a specialist, they’ll arrange it for you by submitting a referral request.

The PCP will:

• Refer you to a specialist in your HMO plan’s provider network
• Work with your insurer to get a referral approved
• Monitor what is diagnosed and what care you get from the specialist
• Turn in any additional referrals needed, such as for other specialists, lab work or hospital stays.

A referral says that your HMO plan covers some or all the costs for covered services. If the specialist recommends tests or procedures, ask if they have checked to make sure all are covered.

Three things you’ll want to make sure happen:

• Don’t go without a referral. Specialist visits require your PCP to work with your insurer for a referral. The referral must be for a specialist who is in your HMO network. You do not need a referral to see an in-network OB/GYN.
• When the specialist’s office calls to arrange your visit, be sure to ask if they are in your HMO network.
• If you are getting ongoing treatment for a health issue, ask your PCP about a standing referral. A standing referral from your PCP will allow you to see your specialist without needing a new one for each visit. 

It’s your right to ask questions to make sure your doctors are using your HMO the right way. If you don’t have a referral or if you have tests that aren’t a covered benefit, your HMO may not cover the costs for you.

You can get more information about your HMO health plan at any time. Just log in to or sign up for your secure member account online or through the BCBSTX App. Download it in English or Spanish from the Apple App Store  or Google Play.