healthcare referral

What is a healthcare referral?

In healthcare, a referral happens when one medical professional – often the patient’s primary care provider (PCP) – sends the patient to see another medical provider, usually a specialist.

A referral can be made for a variety of reasons. Maybe specialty care is needed to address the patient’s needs and complete the treatment process. A doctor might make a referral because the referring provider isn’t certain of the correct diagnosis, or the patient wants a second opinion or might simply connect better with a different provider.¹

A healthcare referral may be valid for a limited amount of time and/or specialty care visits. The specifics of this will vary depending on your health plan and the medical system you use.

Do I need a referral to see a specialist?

If your health plan is an HMO (health maintenance organization) or POS (point of service) plan, the plan may only cover specialty care if you’re referred to the specialist by your PCP. This is not always true of modern plans however. HMOs that don’t require PCP referrals to see a specialist are available in some areas.²

For some types of services, such as lab work³ or certain mammogram screenings,⁴ the facility may require an order or referral from your doctor before they can schedule the procedure.

Note that under the ACA, a health plan cannot require a woman who wants coverage for obstetrical or gynecological caret (OB/GYN) to obtain a referral to an OB/GYN in-network specialist.⁵

If your health plan or the medical facility requires a referral, you’ll need to see your PCP and get a referral before receiving the additional care. But even if a referral isn’t required, it’s a good idea to keep your PCP in the loop. They play an important role in coordinating your care and ensuring that you’re seeing the necessary specialists and receiving the treatment that meets your medical needs.

How do I get a healthcare referral?

If you need a healthcare referral, you should contact your PCP first. After they consider the symptoms you’re experiencing, they will be able to refer you to the appropriate specialist or provide other guidance.

Your PCP may want to see you in person or schedule a telehealth visit, or they may submit the referral without a visit based on the information you provide and their history with you.⁶

Depending on the complexity of the case, your PCP might refer you to more than one specialist. For example, you might be referred to both a cardiologist and a pulmonologist if you’re exhibiting symptoms of heart and/or lung conditions.⁷ Or if you present to your PCP with multiple issues that need to be addressed, they may provide you with multiple referrals. For example, you might need a colonoscopy (necessitating a referral to a gastroenterology practice) and you may also need to have a suspicious mole checked, which will require a referral to a dermatologist.

If your health plan requires prior authorization for the care you need, your PCP will work with your plan to get the prior authorization approved. If prior authorization is needed, it will be in addition to the referral; a referral will not fulfill prior authorization requirements. If the prior authorization request is denied, you and your medical team can file an appeal with your health plan.