Referrals & Pre-approvals
Susanne had foot pain for years. It got so bad she could not walk a few blocks without her feet hurting. “My doctor said it was very hard to get an appointment with a podiatrist. He finally managed it and I went to this very nice fellow and he made me arch supports and it has made a huge difference in my life.”
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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.
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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.
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