Do I Need a Referral From My Primary Care Physician with a PPO Plan?
A Preferred Provider Organization, or a PPO, is a network of providers in your area organized by an insurance company that accepts an agreed upon cost for services used by any member. Your provider network is not always limited to one health system. Insurance companies partner with multiple health systems that they consider “in network.” Your employer will be able to equip you with the insurance company’s provider link to make your search easier.
But do you need a referral to a specialist if you have a PPO plan? The answer is you do not. Unlike a Health Maintenance Organization (HMO), which requires a referral from your primary care physician to visit a specialist, PPOs enable clients to visit specialists if they are in network. If you injured your shoulder, for example, you would not need to seek a referral from your primary care physician before scheduling an appointment with an in-network specialist. If the specialist is in network, their costs will also, generally, be lower.
However, a referral is not “prior authorization,” which is typically necessary for inpatient hospital services or if there is a procedure/medicine that may not be covered on your current insurance plan. Your doctor will have to request the prior authorization on your behalf to the insurance company.
When it comes to questions about your health insurance plan, we have the answers. Contact your ARC agent today with any questions you may have about your plan.
Resources
https://blog.stridehealth.com/post/plan-network-types-hmo-ppo-epo
