Do I Need a Referral to See a Specialist With Medicare?
With Original Medicare, in most cases you don't need a referral to see a specialist. With Medicare Advantage, you may need one: in most HMOs you do, and PPOs generally don't require one. Your plan's rules decide, so ask your plan and the office before the visit.
What Medicare.gov Says
| Coverage | Referral to see a specialist |
|---|---|
| Original Medicare | In most cases, you don't need one. |
| Medicare Advantage HMO | In most cases, you do. |
| Medicare Advantage PPO | No. |
A referral is a question of coverage rules. Which kind of specialist suits you is a question for your doctor, and this site can't answer it.
This guide explains how to find and check care. It can't tell you which doctor or treatment is right for you. Your doctor or plan can.
How to Check
- Look at your card to see whether you have Original Medicare or a plan.
- If you have a plan, call the number on your card and ask, "Do I need a referral to see this doctor?"
- Call the specialist's office and ask, "Do you need a referral or any records before a first visit?"
- If you need one, ask your primary care doctor's office how to get it.
For coverage questions, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Common Questions
Does this site show who requires a referral?
No. The public file doesn't say. Ask your plan and the office.
What if the office and my plan disagree?
Your plan decides what it covers, so ask the plan to confirm.
Is a referral the same as prior approval?
They are different rules. Medicare.gov says to follow your plan's rules, such as getting prior approval when required. Ask your plan which apply.