How to know if you need a referral and how to get one

BCBSOK Connect Team — Mon, 20 Oct 2025 21:30:42 GMT

Current Revision posted to Ask BCBSOK by BCBSOK Connect Team on 10/20/2025 9:30:42 PM

Q. Do I need a referral? How do I get one?

We know referrals can seem confusing, so we’ve put together a guide to help you understand how they work.

If you’ve been seeing your primary care provider (PCP) for a while, chances are you have a bond based on trust. That’s a good thing. After all, your PCP is all about your good health. But what if you need to see someone else? A specialist who can treat you for a specific illness or condition?

When you are covered under an HMO plan and need to be treated by a specialist, your PCP must submit a referral request. The request is reviewed to make sure it meets your plan’s approval requirements. When the referral is approved, we notify your PCP and they’ll let you know.

PPO plans do not require a referral before treatment — even if you go to a specialist. Still, some specialists may want you to see your primary doctor before coming to see them.

Though PPO plans don’t require referrals, some services may need a pre-approval — also called prior authorization — before your claim can be processed or services are provided.

If you’re planning an inpatient hospital stay, it will probably require pre-approval before you are admitted. Many plans also require that we be notified within a certain time after you are admitted to the hospital for an emergency stay. Your doctor can contact us to request pre-approval for you.

Some outpatient procedures also require pre-approval. There isn’t a complete list of all the services that require approval since they vary from plan to plan. You or your doctor can always contact us directly to learn about your plan’s requirements for any procedure.

If your service does need pre-approval, your doctor will submit a letter explaining reasons for the recommended service. Any documents that support the request (medical records, test results) should also be sent. Once we receive the request, it is reviewed by a member of our medical team. When a decision is made, your doctor will be notified.

We understand the referral and approval processes can seem daunting. That’s why our customer service team is here to answer any question you or your doctor may have as you plan your health care.

Contact our customer service department at the number on your member ID card. You can also reach us through private message here on Connect or via the Message Center on Blue Access for Members^SM.We’re happy to verify information for your doctor.

Next time you talk with your doctor about your health care plan, make sure you discuss any steps you need to take to verify your insurance coverage.

Originally published 9/29/2016; Revised 2017, 2018, 2019, 2021, 2024

Tags: PPO, Referrals, Prior Authorization, Using Health Insurance, Customer Service, HMO

How to know if you need a referral and how to get one

BCBSOK Connect Team — Thu, 25 Apr 2024 17:42:41 GMT

Revision 5 posted to Ask BCBSOK by BCBSOK Connect Team on 4/25/2024 5:42:41 PM

Q. Do I need a referral? How do I get one?

We know referrals can seem confusing, so we’ve put together a guide to help you understand how they work.

PPO plans do not require a referral before treatment — even if you go to a specialist. Still, some specialists may want you to see your primary doctor before coming to see them.

Though PPO plans don’t require referrals, some services may need a pre-approval — also called prior authorization — before your claim can be processed or services are provided.

We understand the referral and approval processes can seem daunting. That’s why our customer service team is here to answer any question you or your doctor may have as you plan your health care.

Next time you talk with your doctor about your health care plan, make sure you discuss any steps you need to take to verify your insurance coverage.

Originally published 9/29/2016; Revised 2017, 2018, 2019, 2021, 2024

Tags: PPO, Referrals, Prior Authorization, Using Health Insurance, Customer Service, HMO

How to know if you need a referral and how to get one

BCBSOK Connect Team — Wed, 14 Apr 2021 18:04:44 GMT

Revision 4 posted to Ask BCBSOK by BCBSOK Connect Team on 4/14/2021 6:04:44 PM

Q. Do I need a referral? How do I get one?

When you are covered under an HMO plan and need to be treated by a specialist, your PCP needs to submit a referral request. The request is reviewed to make sure it meets your plan’s approval requirements. When the referral is approved, we notify your PCP and they’ll let you know.

We know referrals can seem confusing, so we’ve put together a guide to help you understand how they work.

PPO plans do not require a referral before treatment — even if you go to a specialist. You may want to contact the doctor’s office ahead of time to see if they have any special requirements. Some specialists may want you to see your primary doctor before coming to see them.

Though PPO plans don’t require referrals, some services may need a prior authorization before your claim can be processed or services are provided.

If you’re planning an inpatient hospital stay, it will probably require prior authorization before you are admitted. Many plans also require that we be notified within a certain timeframe after you are admitted to the hospital for an emergency stay. Your doctor can contact us to request prior authorization for you.

Some outpatient procedures also require prior authorization. There isn’t a complete list of all the services that require prior authorization since they vary from plan to plan. You or your doctor can always contact us directly to learn about your plan’s requirements for any procedure.

If your service does need a prior authorization, your doctor will submit a letter explaining reasons for the recommended service. Any documents that support the request (medical records, test results) should also be sent. Once we receive the request, it is reviewed by a member of our medical team. When a decision is made, your doctor will be notified.

We understand the referral and prior authorization processes can seem daunting. That’s why our customer service team is here to answer any question you or your doctor may have as you plan your health care.

Contact our customer service department at the number on your identification card. You can also reach us through private message here on Connect, or via the Message Center on Blue Access for Members^SM.We’re happy to verify information for your doctor.

Next time you talk with your doctor about your health care plan, make sure you discuss any steps you need to take to verify your insurance coverage.

Tags: PPO, Referrals, Prior Authorization, Using Health Insurance, Customer Service, HMO

How to know if you need a referral and how to get one

BCBSOK Connect Team — Thu, 18 Jul 2019 01:28:30 GMT

Revision 3 posted to Ask BCBSOK by BCBSOK Connect Team on 7/18/2019 1:28:30 AM

Q. I’m having a service done, do I need a referral? How do I get one?

When you are covered under an HMO plan and need to have a service performed by someone other than your primary care provider (PCP) your provider will need to submit a referral request. This request will be reviewed under your plan to make sure it meets the approval requirements. When the referral is approved we’ll notify your PCP and they’ll let you know. We know referrals can get confusing so we’ve put together a helpful guide to this process.

PPO plans do not require a referral before having a service performed; even if you’re going to a specialist. However, you may wish to contact the doctor’s office who will be performing your service to see if they have any special requirements; for example, some specialists may want you to see your primary doctor before coming to see them.

Though PPO plans don’t require referrals, some services may need a precertification or prior authorization before your claim can be processed or before services are rendered.

If you’re planning an inpatient hospital stay those typically do require a precertification before you are admitted. Additionally, many plans do require we be notified within a certain timeframe after hospital admission for emergency stays. Your doctor can contact our precertification department for you to complete this process.

There are some outpatient procedures, for example some diagnostic radiology procedures, which may require your doctor to submit a request for approval or prior authorization . While there isn’t a comprehensive list available of all the services that require authorization, as this can vary from plan to plan, you or your doctor can contact us directly to check your plan’s requirements for any procedure you need.

If your service does need a prior authorization your doctor can submit a letter explaining why they are recommending the service along with any documents that support this request, such as medical records or test results. Once we receive this request it will be reviewed by a member of our medical team. When a decision is made your doctor will be notified and you can work together to take the next steps for your care.

We understand these referral, precertification, and prior authorization processes can be hard to understand. That’s why our customer service team is here to help answer any question you, or your doctor, may have as you plan out your health care needs.

You can contact our customer service department at the number on your identification card, through a private message here on Connect, or through the Message Center on Blue Access for Members for information on your plan’s requirements for a service. Our provider services area can also verify this information for your doctor.

Next time you talk with your doctor about your health care plan make sure you discuss any steps you need to take to verify your insurance coverage.

Tags: PPO, Using Health Insurance, Customer Service, HMO

How to know if you need a referral and how to get one

BCBSOK Connect Team — Tue, 19 Jun 2018 16:38:50 GMT

Revision 2 posted to Ask BCBSOK by BCBSOK Connect Team on 6/19/2018 4:38:50 PM

Q. I’m having a service done, do I need a referral? How do I get one?

Though PPO plans don’t require referrals, some services may need a precertification or prior authorization before your claim can be processed or before services are rendered.

Next time you talk with your doctor about your health care plan make sure you discuss any steps you need to take to verify your insurance coverage.

Tags: PPO, Using Health Insurance, HMO, customer service

How to know if you need a referral and how to get one

BCBSOK Connect Team — Thu, 29 Sep 2016 18:37:34 GMT

Revision 1 posted to Ask BCBSOK by BCBSOK Connect Team on 9/29/2016 6:37:34 PM

Q. I’m having a service done, do I need a referral? How do I get one?

Though PPO plans don’t require referrals, some services may need a precertification or prior authorization before your claim can be processed or before services are rendered.

Next time you talk with your doctor about your health care plan make sure you discuss any steps you need to take to verify your insurance coverage.

Tags: PPO, Using Health Insurance, HMO, customer service