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Home > Specialist Care

Seeing a Specialist

Doctor looking at an xray

 

Your primary care doctor may refer you to a specialist if you need a diagnosis, advice, or a treatment that requires special training.

 

Topics on this page:

 

How to see a specialist

In many health plans, your primary care doctor must refer you to the specialist. The specialist must be in your health plan’s network, and is usually in your medical group. Sometimes, your medical group or health plan must approve the referral. Learn more about referrals and pre-approvals... 

 

Finding a specialist

  • Ask your doctor for recommendations.
  • Ask your health plan for a provider directory or look on the plan’s website.
  • If you need a treatment or procedure that is risky, look for a specialist who has done it many times.
  • The American Board of Medical Specialties has information on more than 100 different kinds of specialists.

 

New time limits on waiting for appointments

California is the first state to set limits on how long a patient has to wait to see a doctor (including a specialist).  You have the following rights if you are in an HMO or Anthem Blue Cross or Blue Shield PPO (plans regulated by the Department of Managed Health Care):

  • If you need an urgent care appointment that requires approval, you should be able to see the specialist within 96 hours.
  • If the urgent care appointment does not require apporval, you should be able to see the specialist within 48 hours.
  • If you need a non-urgent appointment, you should be able to get it within 15 work days.

More information about timely access protections...

 

Problems getting specialist care

If you have a problem getting a referral approved by your health plan: 

  • Ask your doctor to help you get the referral approved, or get the appointment scheduled.
  • Ask your plan to approve a referral to a specialist outside the network. Your doctor will have to explain why you need to go outside the network.
  • You can file a complaint with your plan if you cannot get the appointment you need.

 

Resources

OPA materials: How to Use Your Health Plan

American Board of Medical Specialties - Information about specialists' training
1-866-275-2267   www.abms.org

Department of Managed Health Care - Information about health plans 
1-888-466-2219    www.healthhelp.ca.gov

 

Related Topics

Referrals and pre-approvals

How to file a complaint

Health Plan Problems?

Call 1-888-466-2219

Find other resources...

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