A referral is a request by the Primary Care pHysician (PCP) to send a patient to a specialist for diagnostic intervention, consultation and/or treatment.
Each insurance company has its own rules and regulations regarding the referral process. Certain insurance companies require that the PCP obtain authorization before the referral can be generated. Patients are advised to read their insurance policy manual or contact the member service department to obtain their plan’s guidelines for referrals.
- Make an appointment with his/her PCP (if applicable) to determine if a referral to a specialist is warranted.
- The PCP must refer to an in-network specialist in order for maximum benefits to be considered.
- A specialist should first consult with the patient’s PCP before referring to another specialist
- Referral approvals usually take 48 to 72 business hours and patients are advised to schedule their appointments with the specialist accordingly.
- Same day referrals will only be approved in emergency situations.
- There is usually a time limit for which the patient may see the specialist before the referral expires.
- Patients are responsible for making sure the referral limits have not elapsed when making additional
- Retroactive referrals will not be approved by the PCP.
- Patients should be aware that an approval for a referral is not a guarantee of payment. All claims are subject to review by the insurance company.