What People Get Wrong About Getting a Referral and Prior Authorization
Getting a Referral and Prior Authorization: what people commonly get wrong, set against what published US guidance says.
Skipping a required step can leave you with the full bill, and knowing your rights is the difference between waiting and chasing.
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 the guidance actually says
The published position, before we get to what people believe instead.
| 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 |
Where people go wrong
These are widely believed and not supported by the guidance above.
- 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
What to do instead
- 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
The part that is genuinely uncertain
Guidance changes, and it changes because evidence does. The figures above reflect current US guidance from the bodies named at the foot of this page; where those bodies revise their position, theirs is the account to follow rather than this one.
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
- New to Getting a Referral and Prior Authorization? Start Here
- A Q and A on Getting a Referral and Prior Authorization
- 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.
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