Frequently Asked Questions - Referrals and Physician Networks


Q. Is it legal for my HMO to require me to use certain providers or networks?

A. Yes. An HMO can limit its reimbursement to a network of providers as long as it complies with certain rules of access:

  • The maximum travel distance or time is the lesser of 30 miles or 30 minutes to the nearest primary care, mental health and general hospital provider.

  • Specialists must be available within 60 miles or 60 minutes.

  • Certain highly specialized care such as organ transplants may be provided by centers of excellence beyond 60 miles.

  • Emergency care must be covered even if services were provided by a non-network provider. In addition, the HMO must pay for highly specialized medically necessary care that is not available in network.

Q. When do I need a referral?

A. Your HMO plan may require you to get a referral from your primary care provider in order to see certain specialty providers. Your evidence of coverage, contract or benefit summary will identify services that require a referral. You can also call your HMO's member services department to verify when a referral is necessary.

Q. What else do I need to know about referrals?

A. A referral may be given for a specific number of visits or time period. You may need to obtain a new referral if you change primary care providers or your clinic system. If you have a chronic health condition that is monitored by a specialist, you may also seek a standing referral. This type of referral allows for more visits over a longer time period.

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For more information, or to file a complaint, contact the MCS at 651-201-5100 or 1 800-657-3916.

Updated Monday, 06-Jan-2014 13:29:47 CST