Do I need a referral to see a specialist?
Whether you need a referral comes down to what type of insurance plan you have. Pick yours below to see how that type usually works, and what to ask your insurer to be certain.
This is not a coverage determination. It describes how these plan types generally work. Only your insurer can tell you what your specific plan covers, and rules can change each plan year.
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How each plan type usually works
| Plan type | Referral usually needed? | Notes |
|---|---|---|
| HMO | Usually yes | Primary care physician coordinates care. Visits without a referral are commonly not covered. |
| PPO | Usually no | Direct specialist access, including out of network at higher cost. |
| EPO | Often no | Direct access, but in-network only. Out-of-network care is generally not covered. |
| POS | Usually yes | Referral needed for the in-network rate. Out-of-network may be covered at a lower level. |
| Medicare Advantage | Depends | Follows HMO or PPO rules depending on how the plan is structured. |
| Original Medicare | Usually no | Any provider who accepts Medicare assignment. |
| Medicaid | Depends | Varies by state and by whether you are in a managed care plan. |
| No insurance | No | No plan to require one. Ask for the self-pay price when booking. |
What to ask your insurer
Does my plan require a referral to see a [specialty], and is Dr. [name] in network?
Call the member services number on the back of your insurance card. Confirm before booking rather than after the visit.
If terms such as deductible, copay, coinsurance, provider network, HMO, and PPO are unfamiliar, Guided Personal Finance has a plain-language guide to how health insurance works (opens in a new tab, external site). Your insurer remains the only source that can confirm the terms of your actual plan.
Frequently asked questions
- Do I need a referral to see a specialist?
- It depends on your plan type. HMO and POS plans typically require one; PPO, EPO, and Original Medicare typically do not. Only your plan can confirm what applies to you.
- What is the difference between a referral and prior authorisation?
- A referral comes from your primary care physician and points you to a specialist. Prior authorisation comes from your insurer and approves a specific test or procedure. Some plans require both, and one does not substitute for the other.
- How do I find out what type of plan I have?
- Check your insurance card first — the type is often printed on it. If a primary care physician is named, that usually means an HMO or POS plan. Otherwise call member services.
- What if I see a specialist without a required referral?
- The visit is commonly not covered and you may be billed in full. Some plans cover it at a reduced rate. Confirm before booking.
- Do I need a referral for emergency care?
- No. Emergency care never requires a referral. If you think you are having an emergency, call 911.
Related reading
- How to get a referral (and when you actually need one)
- Primary care vs. specialist: who to see first
- Browse all specialty guides
Find out which type of doctor to see
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