Referral Procedure

Some health maintenance organizations (HMOs) require a referral from a primary care physician before an enrollee can see another plan provider. All HMOs require the enrollee to have a referral that has been approved by the plan before going to a non-plan provider. The certificate booklet includes information on the procedure to follow and any notification requirements.

A managed care plan may not require a referral from a physician for services from a plan chiropractor. It must also allow a woman to receive obstetrical and gynecological services from a plan physician who specializes in obstetrics or gynecology without requiring a referral from her primary care provider.

Managed care plans must have a procedure allowing for standing referrals. A standing referral authorizes an enrollee to be seen by a specialist provider for a specific duration of time or specific number of visits without having to obtain a separate referral from the primary provider for each visit to the specialist.

If an enrollee goes to a non-HMO provider without an approved referral, the claim for those services will not be reimbursed by the HMO. Enrollees have the right to file a grievance when a referral is denied.