Referral
Written authorization from a primary care provider for a patient to receive care from a specialist or for specific services.
Updated
A referral is written authorization from a primary care provider (PCP) directing a patient to receive care from a specialist, facility, or for specific services. Referrals are commonly required by health maintenance organization (HMO) and point-of-service (POS) plans before specialty care is covered.
Without a required referral when one is mandated by the plan, the claim may be denied or paid at a lower benefit level.
In practice
Prior to specialty visits, billing and front-desk staff verify whether the plan requires a referral and whether one is on file. Referral data is captured during eligibility verification to prevent denied claims and patient surprise bills.
Commonly confused with
- Prior authorization: A referral is a clinician's authorization for a patient to see a specialist; prior authorization is the payer's approval, based on medical necessity, for coverage of a specific service.