Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

Topic Area: Provider networks and referrals

I need to see a specialist and can’t find one that’s in my network. Does this mean it’s not a covered benefit?

When your doctor needs to refer you to a specialist for care, first talk with the doctor’s office staff to see if there is an in-network specialist contracted with your insurance plan. Remember that the doctor’s office may not know what providers are included in your insurance plan network.  If in doubt, call your plan customer service directly.

If you find that your insurance network does not include the needed specialty provider, coverage for services depends on your insurance plan benefits. 

Contact your insurance plan to see if there is an in-network specialist that wasn’t listed in other resources. They have the most current information.

If your plan tells you:

  • There is an in-network specialist. Contact your doctor’s office and ask for a referral to the identified provider if required. Not all specialty care may require a referral.
  • There is not an in-network specialist. Ask your insurance plan about coverage for out-of-network specialty care when no in-network specialist is available. 

There may be an authorization and/or referral process for your provider to request out-of-network approval before you see the specialist. If required, be sure you get the approval and/or referral before seeing the specialist.  If you don’t have the authorization in place, you could be responsible for most or all of the cost. Ask you plan about the amount of coverage for out-of-network services.

You can see an out-of-network provider without a referral or authorization, but be aware that out-of-network benefits vary by plan, so check with your insurance plan about how much is covered and how much you will owe, which may be all of the costs.


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