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HMOs Unique Features And Lingo

Specialist Referrals

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If a Primary Care Physician (PCP)decides a member should visit a specialist, the PCP provides a Specialist Referral (also known simply as a "Referral") which permits the member to see a specialist.

Depending on the type of referral, the contract and the HMO involved, the PCP's decision to suggest a member see a specialist can be made solely by the PCP or it may need approval by a referral committee, usually a group of doctors within the practice that meet regularly to review referral requests.

Upon receiving approval, the PCP decides to which specialist a member will be referred.

The patient generally retains the right to see another doctor within the system instead of the doctor recommended by the PCP.

Many HMOs either permit multiple referrals so the member does not need to seek permission each time he or she wants to see a specialist, or have eliminated the referral requirement all together. Either of these options are particularly useful for people with a life changing condition who meet frequently with specialists.

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