Booking specialists, tests and hospital care under a policy

Key rules

• Specialists: In-network specialists can usually be booked directly, with no GP referral.
• Authorisation: Scans, surgery and scheduled admissions usually need your insurer's approval before you book.
• Basic tests: Basic blood tests, X-rays and ultrasounds usually need no authorisation.
• Emergency admission: Tell the insurer within the period in your policy, typically 24 to 48 hours.

You can usually book a specialist yourself

With a private policy you do not need a GP referral. Pick a specialist in your insurer's network (the cuadro médico) and book. This is different from the public system, where a GP referral is required.

A GP is optional. A GP can still be useful for a first opinion, ordering tests, sickness notes for the insurer and prescriptions. You pay for medicines yourself, because policies rarely cover pharmacy costs.

Some cheaper or specific products set extra conditions, so read your policy conditions before you rely on direct booking.

How to book

You have several options:

• The insurer's app or the customer area on its website.
• The insurer's appointment phone line. Some insurers also offer WhatsApp or chat.
• The clinic, hospital or doctor directly, by phone, online or at reception.

Direct booking with the clinic is common for specialists. The clinic checks your policy when you book. Hospital-owned centres often have their own booking apps.

Stay inside the network. A doctor outside it is generally not covered, unless your policy is a reimbursement type.

Which tests need authorisation

Consultations with a GP or specialist, basic blood tests, X-rays and ultrasounds usually need no authorisation.

Authorisation from the insurer is usually needed for:

• MRI, CT and PET scans, nuclear medicine and other high-cost diagnostics
• Biopsies, and endoscopies in some cases
• Scheduled hospital admissions and surgery, including day surgery
• Courses of rehabilitation or physiotherapy
• Chemotherapy, radiotherapy and other high-cost treatments
• Genetic tests, sleep studies and home oxygen therapy

You will normally need a doctor's prescription to request authorisation. The list differs by insurer and product, so your policy conditions are the final word.

Emergencies

Emergencies do not need prior authorisation. If you are admitted through emergency care, tell the insurer within the period in your policy, typically 24 to 48 hours.

The checklist and questions below cover the practical steps.

Checklist

• Check that the specialist is in your insurer's network before booking.

• Book the specialist directly, without a GP referral, through the insurer's app, web customer area or appointment phone line.

• Call or visit the clinic, hospital or doctor to book directly if you prefer, and let them check your policy.

• Ask your insurer for authorisation before booking an MRI, CT or PET scan, biopsy, surgery, scheduled admission or physiotherapy course.

• Book basic blood tests, X-rays and ultrasounds without authorisation.

• Get a doctor's prescription for any test or procedure that needs authorisation.

• Read your policy conditions to see which tests need authorisation under your product.

Frequently asked questions

Do I still need a GP if I have a private policy?

No, a GP is optional under a private policy and you can see specialists without one. A GP is still useful for a first consultation, ordering tests, sickness notes for the insurer and private prescriptions. Medicines are paid by you unless your policy covers pharmacy, which is rare.

Can I see a specialist outside my insurer's network?

Generally no, out-of-network doctors are not covered unless your policy is a reimbursement type. Check your policy type before booking. Some cheaper or specific products also add their own conditions for specialist visits.

Do blood tests and X-rays need authorisation?

No, basic blood tests, X-rays and ultrasounds usually need no authorisation. Scans such as MRI, CT and PET, biopsies, surgeries and scheduled hospital admissions usually do. Ask your insurer before booking anything on that second list.