The very first thing that the referring provider office will check is the patient’s insurance.
This is important because the insurance companies want to make sure that the referral is clinically needed.
Each plan from each payer might have specific referral requirements.
This is why the referring provider office sometimes requires additional time to determine which specialist would be an appropriate fit for the patient to be referred to.
While referring providers office’s staff determines the insurance plan fit, they also find out whether an authorization is required for the referral or not.
If a prior authorization is required the referral center will submit an authorization request for the referral.
This, sometimes, can take up to 14 days.
How about specialist office approval?
Just because the referral is submitted to a specialist office, does not mean that the specialist office has accepted the referral.
Many times specialist providers have a referral process of their own.
Many a time the specialist provider office will ask for supporting documentation for the referral to determine its clinical necessity.
The supporting documentation may include the patient record ( CCDA) and possibly supporting reports (lab reports, x-rays etc.)
Sometimes the specialist office will require the patient to take some additional tests. These tests might require prior authorization from the patient’s insurance.
Is a referring provider obligated to make a referral?
Ethically – yes. Technically – not quite.
Most referring providers will, however, make a referral due to their HEDIS/ MIPS related concerns