Primary care physicians and general practitioners often need to refer patients to a specialist for more advanced diagnostics and specific treatments. This sometimes involves contact the specialist, clinic, or treatment center to get more informed advice while developing a customized treatment plan.

Directing a patient to a specialist for diagnostics or advanced treatment is known as a “Referral” in the world of medical billing. Though there are a few details to be mindful of. Especially when you consider that some specialist treatments and elective procedures might not be covered by certain employer or government assistance medical insurance plans.

One of the important things to keep in mind about a Referral is that you need to note the consent from your primary health care physician before you take an appointment with another specialist. Without proper consent and documentation, the health insurance plan most likely will not be responsible to bear the cost of the appointment, which could leave a lapse in payment.

To ensure that the treatment is covered and there are no interruptions in your revenue stream an official referral must be obtained. In the realm of medical billing, this is a significant record obtained from a provider that outlines the need and reasoning for specialized services from the specialist.

What Are Common Types Of Medical Referrals?

Some specialty services are more common for referrals. The high frequency of referrals also means that these providers and their clinical staff are well-versed in the referral process as well as the kind of documentation needed to set up an appointment that will generate an eventual medical billing claim. Some of the most common types of medical referrals are:

  • Diagnostic (MRI, X-Ray, CT Scan)
  • Vision or Ophthalmologist
  • Gynecological
  • Gastrointestinal
  • Orthopedic
  • Dermatological
  • Cardiovascular
  • Respiratory
  • Physical Therapy

Important Elements Of A Referral For Specialty Services

There are several aspects of medical referrals that need to be minded in the process. An error In any one of the following things could lead to a claim rejection, claim denial, or some other type of unnecessary delay in the revenue stream.

To begin with, the medical referral needs to be in a written format and not verbally told to you for further acceptance by the physician. The referral needs to be officially signed by the physician who has given you a referral. The Primary physician also needs to specify the treatment in the referral for the specialist to consider it.

It’s also important to note that the referral must include a date of approval that allows the patient to use it within the time period of 18 months.

A relevant medical history regarding the patient’s health condition that needs treatment should be provided in the referral. This helps to support the need for care from the specialist, while also helping to reduce the risk of fragmented care.

In an ideal referral, the primary physician would also provide the referral to the patient before they intend to get the specialized services in another clinic or private practice. This makes for a smoother medical process once the treatment has been performed.

The one exception to these requirements is emergency, referrals where a written format is not required. As the overarching goal is to provide the patient with rapid, effective treatment.

How Does The Referral Process Work?

The Referral process has a few important steps and procedures that need to be followed in order to reduce the risk of a denied claim or a delay in the revenue stream.

It starts with the primary care physician who attempts to ascertain if the specialized services are truly required. This might require contacting the specialist clinic to get expert information.

At that point, the request will be reviewed by the patient’s healthcare plan to make sure it meets all pre-approval requirements. Assuming it is approved under the patient’s scope of covert the physician will then be notified.

At that point, a file containing a record of clinical findings, any treatments already performed, and other pertinent information will be gathered and sent to the specialist.

With most referrals, the physician will then help to coordinate the patient’s visit and the referral provided to the specialist. At that point, the specialist being referred will handle medical needs pertaining to the specific condition. Though they will not provide treatment for other non-related conditions. Any other medical conditions will still be handled by the primary care physician.

For example, let’s say a patient is referred to a podiatrist to help address a severe case of foot fungus. The treatment process might take several weeks. If the patient develops a complication related to the foot fungus, the podiatrist will handle the treatment process. If the patient were to sprain their ankle, the primary care physician would still need to generate a second referral for the separate medical issue.

Why Are Medical Referrals Needed

Some medical treatments and medical coverage plans require some form of precertification or prior authorization to ensure full coverage from the medical insurance provider. There are also some plans that require a consult to ensure that the specialist treatment is truly necessary. Though with certain specialist treatments and common diagnostic the medical insurance plans do not require any such referral.

Seeking prior authorizations, consults, and ensuring that the treatment is within the patient’s scope of coverage goes a long way toward preventing claim rejections, claim denials, and interruptions in the revenue stream.


Referrals are somewhat common in the world of medical billing. Though they still do have important steps and other requirements that need to be minded to ensure that the claim it generates will be approved by the patient’s medical insurance provider.

This includes verifying that the specialist treatment for referral is covered under the patient’s health care plan. This might also involve seeking prior authorization or consulting with a relevant expert to ensure that the treatment is indeed indicated for the symptoms displayed.

At that point, the proper documentation needs to be generated and transmitted to the specialist so that all information is carried through to the insurance provider when the final claim is created.