Skip Ribbon Commands
Skip to main content
Navigate Up
Sign In
Home > Referrals and Pre-approvals

Referrals & Pre-Approvals

For many health plans, when you need care from a specialist or another provider, your primary care doctor usually must give you a referral. And often, your health plan or your doctor’s medical group must pre-approve the referral.

Topics on this page

 

Learn the rules for your health plan

Ask your doctor or health plan, or read your Evidence of Coverage. Find out:

  • What services can I get without a referral?
  • What specialists can I see without pre-approval?
  • Do I get pre-approval from my health plan or my medical group?

 

If you need pre-approval to get a service


  • Make sure the service you want is covered by your health plan. You can call the plan and ask.
  • Help your doctor explain why you need the care. Your doctor must explain why the care is medically necessary for you. This is especially important if the care you want is not a common treatment for your condition.

 

The referral and pre-approval process

  • Your primary care doctor writes the referral, and gives it to you or faxes it to the specialist.
  • If necessary, she submits the referral for pre-approval first.
  • It usually takes about five business days to get pre-approval, or three days if your need for care is urgent.
  • You will get a letter saying that your referral was approved or denied. If the referral is denied, the letter will tell you why.
  • Your doctor might be asked to send more information or order more tests before the referral can be approved.

 

If the referral is denied

  • Ask your doctor what you can do. He may be able to submit more information about your need for the referral.
  • If you want, you can file a complaint.

 

Standing referrals

A standing referral allows you to see a specialist without getting a referral from your primary care doctor each time. Your primary care doctor, the specialist, and your health plan must agree that you need a standing referral.

 

Resources

OPA materials: How to Use Your Health Plan Guide

 

Related Topics

Choosing a Doctor

Talking with Your Doctor

Choosing a Treatment

Second Opinions

Language Assistance

Disability Assistance

Talking to Your Doctor about a Complaint

How to File a Complaint

 

Health Plan Problems?

Call 1-888-466-2219

Find other resources...

Twitter

Facebook