- A referral is a request from a healthcare provider for an individual to receive medical care from another provider, such as a specialist. In the context of Medicare, referrals may be necessary for beneficiaries to receive certain medical services or to see certain specialists.
- Under Original Medicare (consisting of Part A and Part B), referrals are generally not required for beneficiaries to see specialists. Beneficiaries are generally free to see any healthcare provider who accepts Medicare and who is willing to treat them.
- However, some Medicare Advantage plans (private health insurance plans that are an alternative to Original Medicare) may require beneficiaries to obtain a referral from their primary care doctor before seeing a specialist. It’s important for beneficiaries to understand the terms of their Medicare Advantage plan and to
discuss any potential referral requirements with their healthcare provider. - It’s also important for beneficiaries to understand that a referral is not the same as a prior authorization, which is a process that requires approval from a payer (such as Medicare or a private insurance company) before providing certain medical services or prescribing certain medications.
- Overall, a referral is a request from a healthcare provider for an individual to receive medical care from another provider. It’s important for beneficiaries to understand any potential referral requirements and to discuss them with their healthcare provider.
