Whether you need a referral to see a specialist depends largely on the type of Medicare coverage you have.
If you have Original Medicare, you generally do not need a referral to see a specialist who accepts Medicare. You can usually make an appointment directly with the specialist.
If you have a Medicare Advantage plan, the rules may be different. Some plans require you to obtain a referral from your primary care provider before seeing certain specialists. Other plans allow you to schedule specialist visits directly, particularly if you have a PPO plan.
Before making an appointment, check:
- Whether the specialist participates in your plan’s network.
- Whether your plan requires a referral.
- Whether the service you need requires prior authorization.
- What your expected copayment or coinsurance may be.
A referral and a prior authorization are not the same thing. A referral generally involves your primary care provider directing you to a specialist. Prior authorization involves the health plan approving certain services before they are provided.
If you are unsure about your plan’s referral requirements or are having difficulty accessing a specialist, contact Regional Financial Security Agency. We can help you understand your coverage and determine what steps you should take.