No referral

What it means

Some plans, often Health Maintenance Organization (HMO) plans, require your primary care doctor to refer you before you see a specialist or have certain services. Your plan says no referral was recorded for this visit.

Whether your plan requires a referral, and for which services, comes from your plan document. This site has not verified a current federal rule on referrals, so it does not state one. If a rule helps you, your plan document or your state insurance department will say so.

Who has to act first

You and both offices. Start with phone calls, not an appeal:

1. Call your primary care doctor’s office. Ask whether a referral was entered, on what date, and under whose name.
2. If one exists, ask the office to send the plan proof of the date. If none exists, ask whether the plan accepts a referral entered after the visit. Plans differ.
3. Ask the specialist’s office to resubmit the claim with the referral number.
4. Call the plan and ask it to reprocess the claim.

If the calls do not work, appeal. For a job-based plan or a non-grandfathered individual plan you have at least 180 days after you receive the denial notice to file the first appeal; your plan may allow more. A Medicare Advantage plan allows 65 calendar days from the date on the notice, and a Medicaid managed care plan 60 calendar days. Check the date on your notice, which controls.

Arguments that work

• The referral existed. Records from the primary care office with a date, or the name of the person who entered it.
• The plan told you it was not needed. If someone at the plan told you no referral was required, your call log, the date and any reference number are your evidence.
• The notice must name the plan provision. Ask for the exact referral rule the plan used and for any internal guideline it relied on.
• Emergencies. A plan that covers emergency department services at all must cover emergency services without prior authorization. That rule is about prior authorization. If your visit was an emergency, say so in your appeal and ask the plan to apply it.
• Urgency. The claims rules also say a plan cannot deny a claim for lack of prior approval where getting approval was impossible or could seriously jeopardize life or health, for example when the patient is unconscious. Whether your plan treats a referral the same way is a question to put to it.

Evidence to gather

• The denial notice and explanation of benefits with the stated reason (you).
• Referral records and dates from your primary care office (that office).
• The plan’s referral rule from the plan document (the plan).
• Your call log with names, dates and reference numbers (you).
• The specialist’s visit notes (the specialist).

What to send

If the referral can be fixed, a corrected claim from the specialist is the fastest route. If you appeal, send a written appeal with the referral records and your call log, and ask for the decision in writing. Use the reprocessing script for the first calls.

When this is not worth an appeal

If your plan document clearly requires a referral, none was ever requested, and no one at the plan told you otherwise, a paper appeal is weak. Still ask the plan whether a late referral can be entered, and ask the specialist about a payment plan or a discount. For next time, confirm the referral is on file before the visit.