Referrals to Specialists
Here are the guidelines that we follow for referrals: Determine and document the reason for the referral in the patient’s medical record. Before contacting the other physician, explain to the patient why a referral is necessary, including what the patient should expect from their visit with the specialist.
In most health plans, your primary care doctor manages your care. This means that you need a referral from your primary care doctor for most other medical services. You may also need prior approval for the service from your medical group or health plan. An approval is also called an authorization. It is important to follow your health plan’s rules about referrals and prior approval. If you do not follow the rules, you usually have to pay all of the cost of the service yourself.