Original Medicare usually does not require a referral to see a specialist. Medicare Advantage rules depend on your plan. A referral comes from a primary care provider and directs you to specialist care. Prior authorization is different: it is approval from the health plan.

Original Medicare

Original Medicare generally lets you schedule with any participating specialist who accepts you as a patient, without a referral. The service must still be covered and medically necessary, and the specialist may require medical records or an informal physician referral as an office policy.

Medicare Advantage

Most Medicare Advantage HMOs require a referral for specialist care and generally require an in-network specialist. Certain services may be exempt.

Medicare Advantage PPOs generally do not require referrals. However, using an in-network specialist usually costs less, and some services may still require prior authorization.

Special Needs Plan rules depend on whether the plan operates as an HMO or PPO and on the specific benefit.

An office may request records or an intake referral even when Medicare does not require a plan referral. That office requirement does not change what your insurance covers. An HMO referral to a specialist may cover several visits but not authorize a later scan: ask about the scan’s approval separately.

Before Making the Appointment

Call the plan and specialist to confirm:

  • Whether a referral is required
  • Whether the specialist and location are in-network
  • Whether the service needs prior authorization
  • What your copayment or coinsurance will be

Get any required referral before the visit. Save the specialist’s name, location, referral dates, and number of allowed visits. For a test or procedure, also ask whether separate plan approval is needed and confirm that the office has received it.

Medicare policy sources last checked: October 8, 2026.