How HMO Works: The Referral Process

Referrals are an important part of saving money when you have an HMO. You’ll want to know when you need a referral and how to use your HMO benefits.

When you sign up for an HMO, your first step is to pick a primary care physician (PCP) to manage your care. You may already have a PCP, such as your family doctor. A child’s pediatrician and a woman’s OB/Gyn can also act as their PCP. 

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 getting a referral.

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 plans cover some or all the costs for covered services. If the specialist plans a lot of 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. All specialist visits require your PCP to work with your insurer for a referral. The referral has to be for a specialist who is in your HMO network.
• 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.   

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.

Originally published February 17, 2015; Revised 2020