What Is a Referral and How Does It Work?
Your primary care provider takes great care of you for many health needs. But sometimes, they may need to send you to a specialist or get you a special test. When that happens, you will hear the word referral.
Referrals can feel confusing. What does it mean? Who does it? How long does it take? What do you have to do?
This guide answers those questions, so you can feel confident and informed every step of the way.
What Is a Referral?
A referral is when your provider sends you to see a specialist or get care outside of NHC. It is a written or electronic request from one provider to another.
A specialist is a doctor with extra training in one area of medicine, like the heart, skin, or joints. Your primary care provider (PCP) is great at caring for your overall health. But when your needs go beyond what they can treat, they send you to someone who has deeper knowledge in that area.
Referral vs. Prior Authorization: What's the Difference?
These two terms are related but not the same thing.
A referral is a recommendation from your provider to see a specialist or get a service.
Prior authorization (also called prior auth or PA) is approval from your insurance company before a service is covered. Your provider or specialist office usually handles this on your behalf.
Not every referral needs prior authorization because it depends on your insurance plan and the type of service. Each referral is reviewed individually. Some services are covered by most plans, some are reviewed case by case, and some may not be covered at all.
Some plans require a prior authorization before a specialist office can see you, and some plans require one after your first specialist visit too. If that is needed, NHC handles it as part of processing your referral (you do not need to manage this yourself). Once your referral is ready, your Referral Coordinator will give you the specialist’s contact information, what the referral is for, and the expiration date. From there, you and the specialist’s office will work out the appointment. If a prior authorization is needed after your first visit, the specialist’s office will work with your insurance to get that covered.
Learn more about prior authorizations
Why Might You Need a Referral?
There are a few common reasons your provider might refer you to a specialist or order a special test.
Your Condition Needs More Expertise
Some health conditions are complex or uncommon. Your PCP may want you to see someone who has more practice treating that specific condition. For example, a dermatologist specializes in skin, so they can do a closer exam, run a skin test, and recommend the right treatment.
Keep in mind that your insurance plan plays a role in which specialists you can see. Not all insurance plans work with all clinics, and some specialists only treat certain conditions. Your care team will help you find the right fit.
You Need a Special Test or Imaging
Some tests (like an MRI, CT scan, or ultrasound) require an order and insurance approval. Your insurance wants to make sure the test is medically necessary before covering it.
Your Insurance Requires It
Some insurance plans require a referral before covering specialist visits. Without one, you could end up paying the full cost out of pocket. Your care team will help determine the next steps for getting you the specialty care you need.
A Referral Can Help You Get Seen Faster
In some areas of medicine, there are not enough specialists to meet demand. A referral from your provider shows the specialist's office that the visit is medically necessary and gives them a sense of how urgent your situation is. This can help move you up the waitlist.
What Kinds of Referrals Are There?
Referrals can be for many different types of care.
- Specialist referrals: Cardiology (heart), dermatology (skin), neurology (brain and nerves), or orthopedics (bones and joints)
- Imaging referrals: X-rays, MRIs, CT scans, or ultrasounds
- Physical therapy or other treatment services
- Mental health or behavioral health services
- Dental referrals
- Preventative screenings like mammograms
At NHC, our Referral Coordinators each specialize in different areas, some handle imaging, others manage specialty referrals like cardiology and dermatology, and some focus on internal referrals within NHC, like dental or behavioral health. With 100 to 200 referrals placed every day, this dedicated team works hard to make sure you get the care you need.
How Does the Referral Process Work?
Here is what typically happens from start to finish:
Step 1: Your Provider Decides a Referral Is Needed
At your appointment, your provider assesses your condition. If they feel you need a specialist or special test, they will tell you and explain why. You can always ask questions, including why this type of specialist and what to expect.
Step 2: NHC's Referral Coordinators Take It from There
Once your provider submits the referral, NHC's Referral Coordinator team gets to work. They:
- Verify your insurance coverage to avoid surprise costs
- Process the referral and send it to the right specialist or imaging center
- Provide you with information on where your referral was sent
- Share this information through MyChart (if you have it set up), by letter, or by phone
- Follow up on referrals that are time-sensitive or require extra coordination
You and your care team work through this together. In some cases, your Referral Coordinator may need your input (like choosing a specialist location) before the referral can move forward. Once it’s sent, you will work directly with the specialist’s office to schedule your appointment.
Keep in mind that all referrals have an expiration date. Your Referral Coordinator will share the expiration date along with the specialist’s contact information, so make sure to call and schedule before it expires.
Step 3: Insurance Approval (If Required)
If your insurance requires prior authorization, your provider's office or the specialist’s office will request approval on your behalf. The insurance company will review your medical records and decide if the service is medically necessary.
This step can take time. Your provider does not control how quickly the insurance company responds or what they decide.
Step 4: Scheduling Your Appointment
Once the referral is approved, your Referral Coordinator will share the specialist’s contact information with you. It is your responsibility to call the specialist’s office directly to schedule your appointment.
If you do not hear anything within a reasonable amount of time, reach out to NHC's Referral team. They can check on the status for you.
Step 5: Your Specialist Visit
When you see the specialist, come prepared with questions. NHC sends your medical records ahead of time, so you should not have to repeat everything from scratch. If you are unsure what to bring, call the specialist’s office before your appointment.
Step 6: Your PCP Stays in the Loop
After your specialist visit, the specialist will typically send a report back to your PCP. This helps your care team stay connected and make the best decisions for your ongoing care.
How Long Does a Referral Take?
Referral timelines can vary based on several things. In general, it can take anywhere from a few days to a couple of weeks (or longer) depending on:
- Your insurance company's review process
- The specialist's availability and wait list
- How quickly records and paperwork are processed
- Whether the referral is clinically urgent or routine
At NHC, our Referral Coordinators check on urgent referrals at least every two weeks. If there is a delay, like a specialist clinic that is hard to reach or a long wait list, they will work to find another option for you.
Some specialty areas, like neurology, have long wait times due to limited providers. NHC's team will always do their best to find the fastest path to the care you need. In some cases, your insurance or diagnosis may limit which clinics are available, and there may not be a faster option.
Why In-Network Matters
When your provider refers you to a specialist, it is important that the specialist is in-network with your insurance plan. In-network providers have agreed upon rates with your insurance company, which means lower costs for you.
If you go to an out-of-network provider (even with a referral), your insurance may cover much less, or nothing at all. NHC's Referral Coordinators always work to find in-network options for your plan.
A Note on Referral Expiration
Once your insurance approves a referral, there is usually a deadline to use it. The window can be as short as one month or as long as one year, depending on your plan. It may also limit the number of visits covered. Call to schedule your appointment as soon as possible so your referral does not expire before you are seen.
If your insurance changes, you may need a new referral. Ask your new plan about authorization requirements, especially for ongoing treatment.
What About Emergencies?
In an emergency, you do not need a referral. Go to the nearest emergency room or call 911 right away. Your insurance cannot require prior authorization before emergency care.
You may still owe a co-pay or deductible for emergency services, depending on your plan. But getting care comes first — sort out the paperwork after.
How You Can Help the Process Go Smoothly
NHC's Referral Coordinators do most of the heavy lifting. But there are a few things you can do to help things move faster:
- Call to schedule promptly: Once you receive the specialist’s contact information, call to make your appointment right away. Waiting too long can cause delays or let your referral expire.
- Know your insurance: If you know whether you have Providence, Legacy, OHP, or another plan, it helps coordinators find the right in-network provider faster
- Check MyChart: If you have MyChart set up, referral updates may be available there.
- Reach out if you have not heard anything: If you expected a referral and have not received the specialist's contact information, reach out to NHC's Referral team. They can check the status and follow up.
NHC's Referral Coordinators Are Here to Help
If you ever feel lost in the referral process, you are not alone. NHC's Referral Coordinators are dedicated to helping you navigate the system, find the right specialists, and get your appointments scheduled.
If you have questions about a referral, do not hesitate to reach out.
This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Please talk with your healthcare provider for personalized health advice.
Sources
- Neighborhood Health Center. NHC's Referral Coordinators Help You Get the Care You Need. nhcoregon.org/news/nhcs-referral-coordinators-help-you-get-the-care-you-need/
- PeaceHealth. Understanding Referrals: What They Are and When You Need Them. peacehealth.org/healthy-you/understanding-referrals-what-they-are-and-when-you-need-them
- National Association of Insurance Commissioners (NAIC). Understanding Health Insurance Referrals and Prior Authorizations. content.naic.org/article/consumer-insight-understanding-health-insurance-referrals-and-prior-authorizations
- WorldClinic. Doctor Referrals 101: Process, Insurance & Concierge Care. worldclinic.com/blog/doctor-referrals/
- UPMC HealthBeat. How Do Doctor Referrals Work? share.upmc.com/2023/11/how-do-doctor-referrals-work/
Lacey Gonzales, Referral Coordinator Manager
This article was reviewed by Lacey Gonzales, Referral Coordinator Manager at Neighborhood Health Center. Lacey joined NHC in 2019 and brings eight years of experience in non-profit healthcare, supported by a background in education. She oversees NHC’s Referral Coordinator team, ensuring patients receive timely specialty care and that the referral process runs smoothly from start to finish. Lacey is committed to helping patients navigate the referral process with clarity and confidence.