Getting a Referral and Prior Authorization

Key takeaways

• Referral: HMO plans usually require one from your primary care doctor before you see a specialist; many PPO plans do not
• Prior authorization: insurer approval required in advance for some tests, procedures and medicines
• Most useful single change: Ask your doctor's office whether a referral or prior authorization is needed, and whether it has been sent.
• Commonest mistake: Booking a specialist before checking your plan's referral rules.
• See a doctor if any of the signs under "When to get help" below apply to you.

Why it matters

Skipping a required step can leave you with the full bill, and knowing your rights is the difference between waiting and chasing.

The numbers, in one place

Published figures for Getting a Referral and Prior Authorization

Measure	Figure
Referral	HMO plans usually require one from your primary care doctor before you see a specialist; many PPO plans do not
Prior authorization	insurer approval required in advance for some tests, procedures and medicines
If you are denied	you have the right to an internal appeal and, if that fails, an independent external review
Explanation of Benefits (EOB)	a statement from your insurer showing what was billed, paid and what you may owe; it is not a bill
Urgent requests	can be reviewed on a faster, expedited timeline

What helps

• Ask your doctor's office whether a referral or prior authorization is needed, and whether it has been sent
• Keep reference numbers, dates and the names of people you speak to
• Compare each bill with your EOB before paying, and query anything that does not match
• Tell your doctor if symptoms get worse while you wait, since that can change the urgency

What to avoid

• Booking a specialist before checking your plan's referral rules
• Assuming silence means approval, since requests do get lost
• Accepting a denial without asking why and whether to appeal
• Paying a bill before the EOB arrives

In depth

Referrals and prior authorizations are two separate checkpoints that often get confused. A referral is a clinical step: your primary care doctor decides that you need a specialist and sends a request, sometimes with your records. Some plans, especially HMOs and point-of-service plans, require this before they will pay for specialist care. Prior authorization is an insurance step: your plan reviews a proposed test, procedure, medicine or piece of equipment and decides in advance whether it will cover it.

Plans use prior authorization to check that a service is medically necessary and follows their coverage criteria, and to steer care toward options they consider equally effective and less costly. In practice it means your doctor's office submits clinical information, the plan reviews it, and you receive an approval, a request for more information or a denial. Usually the doctor's office handles the paperwork, but you are the one who receives the bill if a required step is missed.

If a request is denied, you have appeal rights. For most plans, you can ask the plan to reconsider through an internal appeal, and if that fails you can ask for an independent external review by an organization not connected to the plan. Medicare and Medicaid have their own appeal processes. Many denials are reversed when more information is supplied, so a first refusal is often the start of a conversation rather than the final answer.

Signs and symptoms

• A specialist's office asks for a referral number before it will book you
• A scheduled test or procedure is postponed while "waiting for insurance"
• Your pharmacy says a prescription needs prior authorization
• You receive a letter saying a service is denied or not medically necessary
• An Explanation of Benefits shows a claim denied for a missing referral

Causes and risk factors

• Plans that require a primary care referral for specialist visits
• Expensive imaging such as MRI, CT or PET scans
• Planned surgery, hospital stays and some outpatient procedures
• Specialty and brand-name medicines, or higher doses than usual
• Durable medical equipment, home health care and some therapies
• Out-of-network care that the plan is asked to cover

How it is checked

To work out what is required, start with your plan documents. The Summary of Benefits and Coverage and the full plan document list which services need a referral or prior authorization. Your plan's member services line, your online account and your doctor's office can confirm the rules for a specific service. Ask for the authorization or referral number once one is issued, and note how long it is valid and how many visits it covers.

When a request is denied, the notice must explain the reason and how to appeal. Read it closely: denials often come from missing information, a coding issue or a policy that requires trying another treatment first. Your doctor can sometimes request a peer-to-peer conversation with the plan's medical reviewer, submit additional records, or explain why the alternatives the plan prefers are not suitable for you.

Related topics

• Medicare and Medicaid Appeals: What the Evidence Actually Says (Medicare and Medicaid)
• What the Guidance Really Says About Reading an Explanation of Benefits (Health Insurance and Costs)
• Physical Therapy Services: Sorting the Evidence From the Noise (Rehabilitation)
• What the Guidance Really Says About Benefits and Financial Support (Long-Term Conditions)

Where to go next

• A Q and A on Getting a Referral and Prior Authorization
• Getting a Referral and Prior Authorization at a Glance
• Using Health Services: The Complete Guide
• The Evidence on Asking for a Second Opinion, Without the Hype
• The Evidence on Leaving Hospital, Without the Hype

When to get help

Do not wait for an approval or specialist appointment if symptoms worsen sharply — new or increasing pain, bleeding, weight loss, or anything that frightens you. Contact your doctor the same day, and call 911 for an emergency, which never needs prior authorization.

Where this comes from

• HealthCare.gov — Referral
• HealthCare.gov — Preauthorization
• HealthCare.gov — Appealing a health plan decision

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.