Understanding Referrals and Specialist Care

“You'll need a referral for that” is one of those sentences that sounds simple and then produces three phone calls. This guide explains what a referral is, how it differs from prior authorization, and how to keep the process moving.

What a referral is

HealthCare.gov defines a referral as a written order from your primary care doctor for you to see a specialist or get certain medical services. In many HMOs you need one before you can get care from anyone except your primary care doctor, and if you don't get it first, the plan may not pay for the services.

In practice a referral does two jobs. It tells the specialist why you're being sent, and it shows your insurer that the visit was arranged the way your plan requires.

Whether you need one depends on your plan

The broad patterns, as described by HealthCare.gov:

• HMO. Usually limits coverage to doctors who work for or contract with the HMO. Many HMOs require a referral to see a specialist.
• POS. You pay less in network, and you need a referral from your primary care doctor to see a specialist.
• PPO. You pay less in network, and you can use out-of-network providers without a referral for an additional cost.
• EPO. Services are covered only if you use providers in the plan's network, except in an emergency.

Plans vary. Your plan documents or member-services line will confirm the rule for yours.

A referral is not prior authorization

The two are easy to confuse. A referral comes from your doctor. Preauthorization, also called prior authorization, prior approval or precertification, is a decision by your health insurer or plan that a service, treatment plan, prescription drug or piece of durable medical equipment is medically necessary. HealthCare.gov notes that it isn't a promise your plan will cover the cost.

You might need one, both or neither. If a specialist recommends a procedure, ask the practice which applies and who will handle the paperwork.

How to keep a referral moving

1. Ask your primary care office how the referral will be sent, and when.
2. Ask whether it names a specific specialist or covers any in-network specialist in that field.
3. A few days later, call the specialist's office to confirm they have received it.
4. Ask how long the referral is valid and how many visits it covers.
5. Keep a copy, or at least a note of the date and the referring clinician's name.

Questions to ask before you book a specialist

Preparing for the first appointment

The National Institute on Aging recommends making a list of what you want to discuss and prioritising your concerns, taking information about your medications with you, and considering whether to bring a family member or friend. The Agency for Healthcare Research and Quality has questions you can adapt for your own visit.

Where Stooly fits

Stooly is a healthcare navigation platform, designed to help people find and compare doctors and keep track of the practical steps around an appointment. Explore the specialties Stooly is designed to support, or read How to Find a Gastroenterologist Near You.