Care from Specialists

When your Primary Care Physician (PCP) determines that you need specialized treatment, he/she will recommend an appropriate in-network specialist or other provider. If your plan requires you to have a referral to see a specialist, your PCP will provide this approval in advance.

A specialist is a doctor who provides health care services for a specific disease or part of the body. Specialists include but are not limited to such doctors as:

  • oncologists (who care for patients with cancer);
  • cardiologists (who care for patients with heart conditions); and
  • orthopedists (who care for patients with certain bone, joint, or muscle conditions).

It is very important that you understand whether your plan requires you to get a referral from your PCP before you see a plan specialist or certain other providers (there are a few exceptions, including certain routine women’s health care). If you are not sure whether or not your plan requires you to get a referral please call Customer Service or speak with your PCP. If your plan requires to have a referral but you do not have one before you get services from a specialist, you may have to pay for these services yourself.

If a specialist for whom you needed a referral wants you to come back for more care, check first to be sure that the referral you got from your PCP for the first visit covers more visits to this specialist.

If there are certain specialists you want to use, talk to your PCP to determine if he/she sends patients to these specialists. Each plan PCP has certain plan specialists that they recommend so that you get the best possible care. This means that the PCP you select may determine the specialists you may see. You may generally change your PCP at any time if you want to see a Plan specialist that your current PCP does not refer to. If there are specific hospitals you want to use, you must first find out whether your PCP uses these hospitals.

Do I need a referral from my PCP to see a specialist?

The specifics of your plan determine whether you need a referral from your PCP to see a specialist or receive specialized services. If you need a referral but do not have one before your visit, you may have to pay for the services yourself, so we recommend that you check with your PCP before seeking specialist care.

Do I need to see a specialist in the Essence network?

Yes. Essence has created an experienced network of contracted specialists. Essence specialists are listed in the “Specialty Care Physicians” section of the provider directory. If you see providers outside our network, there is a higher out-of-pocket cost associated with those services.

What should I do if I get to my specialist visit and the doctor refuses to see me because there is no referral on file?

The specifics of your plan determine whether or not you need a referral from your PCP to see a specialist.

The Plan manages referrals online. If your specialist’s office says that you need a referral but it does not have a referral for you on file, ask the office staff to log on to our website to confirm whether or not a referral has been created.

If there is a referral, the staff will be able to see all relevant details, such as who issued the referral and the time period and number of visits the referral covers. If no referral has been issued, ask the specialist’s office staff to contact your PCP to ask them to submit an online referral through the Essence website. If your PCP will not submit a referral while you are at the specialist's office, contact Customer Service at the number on the back of your ID card for immediate assistance.

What should I do if the specialist wants to see me for a follow-up visit after my initial appointment? Do I need another referral?

If you needed a referral for your first visit, you may need to get another referral for a follow-up visit. You should talk to the referral coordinator (or other designated staff member) at your PCP’s office to find out what your referral is for and how long it is valid. Your specialist’s office can also access the referral online through the Plan website to see how long the referral is valid.

Y0027_20-322 - Last updated 01/30/2020