Physician Billing Services - Frequently Asked Referral Questions

Some insurance companies require you to get a Referral form from your Primary Care Provider in order to receive coverage for specialist visits or procedures. Many services also require Pre-certification or Authorization. Please contact your insurance company to find out is you need a referral, prior authorization or pre-certification before your appointment.

It is extremely important for you to know the requirements of your insurance company for any office visits and/or procedures. This is particularly true if you are in a managed care plan. If you have any questions regarding coverage, you can contact your insurance representative for assistance.

If your health care insurance requires a referral from your primary care physician, you are required to obtain this referral prior to arriving for a specialty physician office visit.

Please contact your primary care physician office prior to arriving for your appointment to obtain the necessary referrals

Referral (FAQs)

1. What is the difference between a referral and an authorization?
A referral enables your PCP to send patients to your insurance carrier's participating specialists. Referrals do not require prior approval. An authorization is required for certain procedures and hospitalization. When an authorization is requested by a physician, it is reviewed by your insurance carrier's medical teams for appropriateness.

2. When do I need a referral?
Whenever your PCP wants you to see a participating specialist, he/she will fill out a referral form. Your PCP will either mail the referral to the specialist, or you can bring it to your first appointment.

3. When can I see a provider without a referral?
Female members may self-refer to OB/GYNs for all OB/GYN related services. Members can also self-refer to a behavioral health provider by using the number on their health plan cards.

4. How do I obtain an Authorization?
An authorization request is submitted by your physician to your insurance carrier for review. Most routine, non-urgent requests are processed within 2 working days although it may take longer depending on the information provided by your physician when the authorization is requested. Usually, requests relating to urgent conditions are processed within 24 hours, and may be phoned in by the physician's office only. Services requiring prior authorization include (but are not limited to) durable medical equipment (DME), in-patient hospital stays, outpatient surgeries, MRIs, CAT Scans, chemotherapy, and radiation therapy.

5. How do I appeal an authorization that has been denied?
You can appeal any denial determination directly to your health plan. All appeal information is included in the denial notice sent to you and your physician.