When Do I Need A Referral?

(HMO) Health Management Organization

Referrals are an important part of an HMO plan because they help your doctor keep track of the care you receive and ensure that the care is right for you. When you join an HMO plan, you select a doctor to be your Primary Care Physician (PCP). Your PCP will provide your routine care, preventive care, and treatment for common illnesses. Your PCP is also responsible for coordinating or overseeing your care. It is for this reason that you will need to have all referrals approved by your PCP.

(PPO) Preferred Provider Option

These plans do not require referrals and patients are allowed to see any specialist without consulting their PCP. It is a good idea to inform your PCP of any specialist you visit so they can communicate with the specialist about your care.

Mass Health (Medicaid)

If you have Mass Health or any other insurance plan through the State of Massachusetts a referral is required for you to see a specialist. The process is the same as an HMO.

Pediatrician in Newton

Before Submitting a Referral You Will Need The Following Information:

Full name of a patient and date of birth
Name of Insurance and ID number
Date of Appointment

The doctor's full name and specialty
The doctor's (NPI) National Provider Identifier number
(click here to look it up)
Doctor's phone and fax number