How HMO Works: Seeing a Specialist

Sometimes, you need to see a specialist for health care issues. If you have an HMO, your doctor can help find the right specialist for your needs.

When you sign up for an HMO, your first step is to pick a primary are physican (PCP) to manage your care. You may already have a PCP, such as your family doctor. A child’s pediatrician and a woman’s OB/Gyn  can also act as their PCP.

But what if you need specialist care for a serious issue? Your PCP can help.

Your PCP can make sure you get the care you need from the right type of specialist. They can also recommend specialists that are in your HMO network, to make sure your visits with the specialist are covered.

The PCP will:

• monitor what is diagnosed and what care you get from the specialist
• turn in any referrals needed for lab work or hospital stays

Two quick things you’ll want to make sure happen:

• Make sure the specialist is in your HMO network. Ask when the specialist’s office calls to arrange your visit.
• If the specialist plans a lot of tests or procedures, ask if they have checked to make sure all are covered. Your PCP may need to get them pre-approved. If you have tests that aren’t a covered benefit, your HMO may not cover the costs for you.   

It’s your right to ask questions to make sure your doctors are using your HMO the right way.

You can get more information about your HMO health plan at any time. Just log in or register for your member account, Blue Access for Members^SM. Visit the My Coverage tab to verify your coverage and identify your medical group and PCP. 

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.

Originally published August 21, 2015; Revised 2020