|Question: Can I see a specialist outside of my HMO provider network?|
You can see any doctor you want--if you're willing to pay for it. But if you want your health maintenance organization (HMO) to pay, you have to play by its rules. HMO guidelines require that you see your primary care physician (PCP) before going to a specialist. Your PCP will want to refer you to a doctor "in network." So, you'll need to explain to your PCP why you need to see the specialist you've selected. In most cases, your PCP should be willing to work with you. If not, consider switching PCPs (if your plan allows). Keep in mind that whether your PCP gives you the referral or not, your HMO can still deny the claim if you go to an out-of-network provider.
If your claim is denied, call the customer service number on the back of your insurance card and talk to the claim representative. He or she may be willing to make a one-time exception. If that doesn't work, you can file a formal appeal with the insurance company. You'll need to explain exactly why you needed to see that particular doctor and why no other doctor would do. Unfortunately, if your appeal is denied, you may just have to pay for the treatment yourself.