Understanding referrals: What they are and when you need them

For many of your health needs, your primary care provider is your go-to. They offer recommendations, provide treatments and prescribe medications for many common concerns and conditions. 
 
But there might be times when your PCP will refer you to a specialist or will want you to get a special test. 
 
Specialists are healthcare professionals who have extra training in fields such as heart, cancer or joint care. 
 
It isn’t always easy to know when you should see a specialist. That’s why your PCP plays an important part in recognizing when to refer you to a provider that fits your needs. 
 
The same goes for special tests. Your PCP can help you determine if the test is worth doing. 
 
Generally, here’s why and when you might need a referral: 

Complex care needs 

There may be times when your PCP suggests you go to a specialist for a diagnosis. This might be because you have a condition that's not common. Or it might be complicated to treat. 
 
In those cases, your PCP may want you to see someone who is familiar with that condition. Or who has lots of practice treating it. 
 
Cancer care is a good example. It can often require surgery as well as radiation, chemotherapy or other types of treatments.  

Insurance requirements 

Your insurance company might require a referral for some types of specialty care or tests. Some care — especially the kind that involves surgery — can be expensive. 
 
Insurance companies want to make sure that medical experts agree that the care is necessary and will be helpful for you. 
 
Check your coverage for referral requirements. Your plan might also have rules about coverage levels for in-network or out-of-network providers.  
 
Contact your insurance company if you have questions about what your plan pays for and whether you need a referral to see a specialist. 

Sharing care 

In some areas of medicine, there aren’t enough providers to meet the demand. It can be difficult to get an appointment because their schedules fill up. This is where your PCP may be able to help. Your referral is proof that a medical expert agrees that you should be seen.   
 
Having a PCP referral also gives the specialty office a better sense the urgency of your situation. And the initial labs or assessments done by your PCP make it possible for the specialist to have more meaningful conversations with you. All of this can reduce potential delays in your diagnosis and treatment planning. 

Here's what else to know about referrals:

Second opinions 

You may want to get a second opinion from a specialist. This is most helpful if it’s for non-urgent surgery. It might also be useful for a complex condition where you'll see a specialist more than a few times. 

Approvals for Tests 

Insurance plans often have stricter rules for imaging studies and other tests such as CT scans or MRIs, which check for tumors, bleeding, injury or infection. You cannot self-refer for most of these. Your PCP or other provider will need to help determine what tests are right for you.  
 
The rules are for your protection. Some tests can be harmful if done more than necessary. For example, CT scans should be done only when needed. This keeps you from getting more exposure to radiation than might be recommended. 
 
Approval by payors for tests might take longer than you might expect. Please know that your provider does not have control over how quickly a test is approved. 

Making the decision 

PCPs can determine if you really need to see a specialist. They can also save you from going to the wrong kind of specialist for your concern.  
 
Your PCP can help you understand what it will mean for you to see the specialist, as well as your risks if you don’t. If you need a referral, PCP offices usually help patients fill out the paperwork to get approval.  But whether or not you actually see a specialist will be up to you.  

Process of getting referral 

If you decide you want the referral, ask your PCP to submit a request to your insurance plan, if approval is required. PeaceHealth’s clinics coordinate this process for PeaceHealth patients. This may include faxing a referral form, sending records, scheduling or managing information received from a specialist.  

Timing of approval 

The time it takes to get approval may vary. And once approved, your insurance company may give you a deadline for using it. The window of time to use the referral could be as little as one month or as much as one year, depending on your plan. The approval might also spell out specific limits such as the number of visits.  
 
Also, note that if your insurance coverage changes, you may need a new referral. Ask your new insurance plan about authorization requirements — especially for treatment you’re currently receiving. 

Continue communication 

When you’re seeing the specialist, you can expect your PCP to communicate with you and your specialty care provider about your medical care. This helps you continue to make informed choices about your next steps in treatment. 
 
Talk to your PCP if you think you have a condition that requires specialty care.