Question

HMO
(Health Maintenance Organization)
If I want to see a doctor outside of my network, I...

Answer 1

Short answer: In an HMO you generally must get care from in‑network providers. If you see an out‑of‑network doctor without prior approval, you’ll usually pay the full cost (except for true emergencies).

What to do if you want to see an out‑of‑network doctor
- Non‑emergency specialist: Ask your primary care physician (PCP) for a written referral and ask your plan for prior authorization. Some HMOs will approve an out‑of‑network referral for medical necessity; others will not.
- Emergency care: Emergency care is typically covered even if the provider is out of network — notify your plan as soon as possible.
- Urgent care while traveling: Many HMOs have limited out‑of‑area/urgent coverage; check your plan rules.
- If denied: You can file an appeal or request a medical‑necessity exception through your plan’s customer service or grievances department.

Practical steps
1. Read your Evidence of Coverage (EOC)/Summary of Benefits to confirm rules and costs for out‑of‑network care.
2. Call your PCP and explain why you want the out‑of‑network specialist; request a referral and that they document medical necessity.
3. Call member services (phone on your ID card): ask whether the out‑of‑network visit can be authorized, what portions (if any) will be covered, and get any approval in writing (or an authorization number).
4. If you see the provider without approval, save all receipts and notes and be prepared to be billed directly by the provider.
5. If denied, ask how to file an appeal and what documentation is needed; consider involving your PCP in supporting the appeal.

Sample things to say when you call member services
- “I want to see Dr. [Name], who is out of network. Can my HMO authorize this visit, and if so what will be covered? Please give me the authorization number and put the determination in writing.”
- “If authorization is denied, how do I file an appeal or request a medical‑necessity exception?”

If you want, tell me: (1) the name of your HMO, (2) whether this is urgent or ongoing care, and (3) whether you already talked to your PCP — I can help draft a call script or an appeal letter.