If you have a Medicare Advantage plan (such as from Humana, UnitedHealthcare, WellCare), your insurance benefits for 2026 may include a referral and/or prior authorization for specialty care.
These rules are set by your insurance plan — not by our office — and they matter.
Established Patient? That Does Not Exempt You
If your Medicare Advantage plan is new for 2026, referral and/or prior authorization requirements may apply even if you have been an established patient in our office for years.
A new plan resets the rules.
Referral Requirements Vary by Plan
Not Medicare Advantage plans require a referral and/or prior authorization. Requirements depend on:
- Your specific plan type (HMO, HMO-POS, PPO, etc.)
- Your individual benefit design
- The reason for your visit
Because of this variability, patients must verify their own coverage directly with their insurance company.
What Our Office Does — and Does Not — Do
Our office:
- Does not verify whether your plan requires a referral and/or prior authorization
- Does not verify referral and/or prior authorization accuracy
- Does not override insurance referral rules
If your plan requires a referral and/or prior authorization and it is missing or does not match the specific reason for your visit, your insurance company may deny the claim.
What Happens If a Claim Is Denied
When a claim is denied due to referral and/or prior authorization requirements, the charges become the patient’s responsibility. Unfortunately, this is not something that can be corrected retroactively.
How to Avoid Problems
Before your appointment:
- Contact your insurance company
- Ask if your Medicare Advantage plan requires a PCP referral and/or prior authorization
- Confirm that the referral and/or prior authorization (if required) must match the reason for your visit
A short phone call ahead of time can prevent delays, denials, and unexpected bills.
Bottom Line
If you have a Medicare Advantage plan for 2026, do not assume last year’s rules still apply.
Know your plan. Know your requirements. Insurance rules are the patient’s responsibility.
Shoal Creek Foot & Ankle Center 