Seeing a Specialist
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:
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...
- 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.
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...
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.
OPA materials: How to Use Your Health Plan
American Board of Medical Specialties - Information about specialists' training
Department of Managed Health Care - Information about health plans
Referrals and pre-approvals
How to file a complaint