A Q and A on Getting a Referral and Prior Authorization

The steps that may be needed before you see a specialist or have a test or treatment covered: a referral from your primary care doctor, approval from your insurer, and the Explanation of Benefits that follows.

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 speak to a doctor" below apply to you.

What is Getting a Referral and Prior Authorization?

The steps that may be needed before you see a specialist or have a test or treatment covered: a referral from your primary care doctor, approval from your insurer, and the Explanation of Benefits that follows.

Why does it matter?

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

Prior authorization for Getting a Referral and Prior Authorization?

Insurer approval required in advance for some tests, procedures and medicines.

If you are denied for Getting a Referral and Prior Authorization?

You have the right to an internal appeal and, if that fails, an independent external review.

Explanation of Benefits (EOB) for Getting a Referral and Prior Authorization?

A statement from your insurer showing what was billed, paid and what you may owe; it is not a bill.

Urgent requests for Getting a Referral and Prior Authorization?

Can be reviewed on a faster, expedited timeline.

What is the single most useful thing to do?

Ask your doctor's office whether a referral or prior authorization is needed, and whether it has been sent.

What is the most common mistake?

Booking a specialist before checking your plan's referral rules.

When should I see a doctor?

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.

More questions, answered

Does prior authorization guarantee the plan will pay?

Not completely. Approval means the plan has agreed the service is medically necessary, but payment still depends on your eligibility on the date of service, your deductible and coinsurance, and the claim matching what was approved. Check your Explanation of Benefits after the service.

Can I get a referral after I have already seen the specialist?

Some plans allow retroactive referrals in limited situations, but many do not. If you have already been seen, contact your primary care office and your plan quickly to ask. It is much safer to confirm the referral is in place before the appointment.

What is step therapy?

Step therapy is a rule that requires you to try a lower-cost treatment first and show it did not work or was not suitable before the plan covers another. Your doctor can request an exception if the first treatment would be harmful, has failed before or is not appropriate for you.

How long does prior authorization take?

It varies by plan and service. Standard requests can take days to a couple of weeks, while urgent requests must be decided much faster. Ask your doctor's office and your plan for the expected timeline, and follow up if you have not heard.

Do I need prior authorization for emergency care?

No. Plans cannot require prior authorization for emergency services, whether at an in-network or out-of-network emergency department. If you are admitted after an emergency, the hospital will usually notify your plan, so focus on getting the care you need.

Who can help me if I am stuck?

Start with your doctor's office and your plan's member services. If you have a job-based plan, your employer's benefits office can help. Your state insurance department or consumer assistance program can advise on appeals, and Medicare and Medicaid have their own help lines.

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

• What People Get Wrong About Getting a Referral and Prior Authorization
• New to Getting a Referral and Prior Authorization? Start Here
• Getting a Referral and Prior Authorization — the reference entry
• 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 speak to a doctor

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.