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A referral, when used in the context of a managed care plan such as an HMO, is a form (electronic or paper) required by the insurance company in order for the subscriber to receive coverage of health care services other than routine care provided by the primary care provider. For example, if you have an HMO, and would like to see an orthopedist for arthritis, your primary care physician would notify your insurance company.
The insurance company would, in most cases, approve your primary care physician's recommendation and process a referral to a local orthopedic care practice. If you get a referral, the insurance company may request additional documentation from your doctor to prove that the referral is truly necessary. Sometimes your insurance company will deny the referral request. In that case, there is a special appeals process, which will take time to resolve and it is no guarantee you will get the referral in the end.
While physician' offices have employees to handle the details of referrals and other insurance documentation requirements, it is ultimately up to the individual seeking the medical care to make sure all referrals have been made prior to receiving services.
|Jennifer Mathes, Ph.D.|