Does BCBS EPO require referral?

Asked by: Cole Berge I  |  Last update: February 11, 2022
Score: 4.7/5 (18 votes)

EPO -- stands for Exclusive Provider Organization -- is similar to an in that it is a healthcare plan that covers eligible services from providers and facilities inside a network. ... Unlike an HMO, EPO participants are not usually required to have a primary care physician or referrals.

Do you need a referral with a EPO?

Most EPOs will not require you to get a referral from a primary care healthcare provider before seeing a specialist. This makes it easier to see a specialist since you're making the decision yourself, but you need to be very careful that you're seeing only specialists that are in-network with your EPO.

What is the difference between BCBS PPO and EPO?

EPO vs PPO eligible expenses

A PPO offers more flexibility with limited coverage or reimbursement for out-of-network providers. An EPO is more restrictive, with less coverage or reimbursement for out-of-network providers. For budget-friendly members, the cost of an EPO is typically lower than a PPO.

Why is EPO more expensive than PPO?

Exclusive Provider Organization. Has a network of healthcare providers that it works with exclusively. ... EPOs are usually cheaper than PPOs due to the restrictions on which healthcare providers you can visit. See also Coinsurance vs Copay.

What is an EPO plan with BCBS?

EPO -- stands for Exclusive Provider Organization -- is similar to an in that it is a healthcare plan that covers eligible services from providers and facilities inside a network.

What does the EPO, PPO, HMO, POS stand for in HEALTH INSURANCE? What is network provider?

27 related questions found

Can you see specialist without referral?

What is a referral? Certain types of health insurance companies will not allow you to see a specialist unless you have a referral from your primary care physician (PCP). He or she will determine what kind of a specialist you need to see and recommend one (or a few) who they trust.

Do all HMOs require referrals?

HMOs generally require a referral for every specialist you see. ... HMOs offer low-cost care if you see a network doctor.

Which type of plan has no network and doesn't require a referral to see a doctor?

A PPO (or “preferred provider organization”) is a health plan with a “preferred” network of providers in your area. You do not need to select a primary care physician and you do not need referrals to see a specialist.

Which insurance plans require referrals?

Generally the referral requirements are:
  • HMO and Network Plans – The PCP must provide a referral for specialty care. Only in-network providers are covered.
  • POS Plans – The PCP must provide a referral for specialty-care services from in-network providers. ...
  • Open Access, PPO and Indemnity Plans – Referrals are never needed.

Does an EPO have a number of doctors and hospitals in its network?

An EPO is a health plan that offers a full-network of doctors and hospitals from which to choose. ... Like a PPO, employees with EPO coverage don't need to get a referral from a Primary Care Physician (PCP) to visit a specialist, as long as the doctor is part of the EPO network.

What is an EPO plan vs HMO?

An Exclusive Provider Organization (EPO) is a lesser-known plan type. Like HMOs, EPOs cover only in-network care, but networks are generally larger than for HMOs. They may or may not require referrals from a primary care physician. Premiums are higher than HMOs, but lower than PPOs.

How do I know if I need a referral?

You Usually Need a Referral and Prior Approval To:
  1. See a specialist, such as a cardiologist if you have a heart problem.
  2. Have a procedure, such as removal of a skin cancer.
  3. Have special tests, such as a colonoscopy.
  4. Have surgery, such as a hip replacement.
  5. Visit urgent care for any urgent medical issues.

Why do Hmos require referrals?

Referrals need to come from your current PCP if you want your plan to cover or help pay for your care when: ... You were seeing a specialist before enrolling in an HMO plan and you want to continue seeing that specialist. You change your PCP while getting care from a specialist; your new PCP may need to issue a new ...

Are referrals covered by insurance?

In order to see a specialist, you'll need a referral from your primary care physician, except in an emergency. Without a referral, your insurance won't cover the cost of your care.

Can I get a referral over the phone?

For those on the type of insurance plan that requires a doctor referral for a specialist, you'll need to go see your primary care physician first. ... In some cases, your physician may provide a referral based on a phone call, but many providers will require that you come into the office for a consultation first.

Can I go directly to a specialist?

Nowadays, many people go directly to specialists, without a referral from another physician. It may not be unusual for someone to see a cardiologist if they are worried about a heart symptom, for example, or to go to the neurologist that helped a friend tackle migraines.

What are three common reasons for a referral?

Generalists' Reasons for Referral

Of nonmedical reasons for referral, meeting perceived community standards of care, patient requests, and self-education were cited most commonly, followed by patient education, reassurance, and motivation.

How do I get a referral for specialist?

Requesting a Referral
  1. Visit Your Primary Care Physician. Your primary care physician will evaluate your concern and, if necessary, make a referral to a specialist. ...
  2. Verify Your Insurance and Referral Information. Contact your insurance company for referral requirements. ...
  3. Make an Appointment with the Specialist.

Do doctors charge for referrals?

Payment by or to a physician or health care institution solely for referral of a patient is fee splitting and is unethical. Physicians may not accept: Any payment of any kind, from any source for referring a patient other than distributions of a health care organization's revenues as permitted by law.

Do doctors get paid for making referrals?

The federal anti-kickback statute bars hospitals from paying doctors for referrals. Together, these rules are intended to remove financial incentives that can lead doctors to order up extraneous tests and treatments that increase costs to Medicare and other insurers and expose patients to unnecessary risks.

Can emergency room refer you to a specialist?

This option can also help you avoid the long wait times typically found in an emergency room. Even if your doctor is unavailable or not an expert in the area of care you need, he or she can refer you to a specialist or another medical professional. ... You can find tips on how to choose a doctor that's right for you here.

Who is responsible for making a referral?

1. Introduction. Anyone who has concerns about a child's welfare can make a referral to Children's Social Care. Referrals can come from the child themselves, practitioners such as teachers, early year's providers, the police, probation service, GPs and health visitors as well as family members and members of the public ...

How do you get a referral for a job?

How to refer someone for a job
  1. Ask internally. Depending on the size of the company, you may need to approach job referrals in a specific way. ...
  2. Write a referral letter. While you may choose to discuss your referral in-person, it is always a good idea to write a referral letter for employers to keep on file. ...
  3. Follow up.

Does EPO cover out of state?

EPO stands for "Exclusive Provider Organization" plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care.

Do doctors prefer HMO or PPO?

PPOs Usually Win on Choice and Flexibility

If flexibility and choice are important to you, a PPO plan could be the better choice. Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.