Understanding Referrals and Specialty Care

Your primary care provider can handle many health needs. But sometimes you need care from someone with more focused training, called a specialist. Getting to that specialist often involves a referral. Knowing how the process works can help you avoid delays and plan ahead, especially if the specialist is far away.

What is a specialist?

A specialist is a healthcare professional who focuses on a specific area of medicine or a group of patients. Examples include:

• Cardiologists (heart)
• Endocrinologists (hormones and conditions like diabetes)
• Dermatologists (skin)
• Orthopedists (bones and joints)
• Psychiatrists (mental health)

What is a referral?

A referral is a written order or recommendation from your primary care provider for you to see a specialist or get certain services.

Referrals serve two purposes:

1. Medical. Your primary care provider shares information about why you need to be seen, so the specialist understands your situation.
2. Insurance. Some health plans, such as many HMOs, require a referral before they will cover a specialist visit. Without one, you may have to pay more or the full cost.

Not every plan requires a referral. Call the number on your insurance card to ask.

How the referral process usually works

Every clinic and plan is a bit different, but the steps often look like this:

1. Your primary care provider recommends specialty care and explains why.
2. The referral is sent. Your clinic sends the referral and your records to the specialist's office.
3. Insurance approval, if needed. Some services also require "prior authorization" from your health plan.
4. The appointment is scheduled. Sometimes the specialist's office calls you. Other times you need to call them.
5. You see the specialist. They may do tests, suggest treatment, or schedule follow-ups.
6. Information is shared back. The specialist sends notes to your primary care provider so your care stays coordinated.

Avoiding delays

Referrals can get stuck. A few ways to keep things moving:

• Ask who is responsible for scheduling. "Will the specialist's office call me, or should I call them?"
• Get the specialist's name and phone number before you leave.
• Follow up if you have not heard anything within the time you were told to expect.
• Check your insurance. Confirm the specialist is in your network and whether a referral or prior authorization is needed.
• Make sure records were sent. Ask the specialist's office if they received your referral and test results before your visit.

When the specialist is far away

In many rural areas, specialists may only be available in larger towns or cities. That can mean long drives, overnight stays, or time away from work and family. Some ideas that may help:

• Ask about telehealth. Some specialists offer video or phone visits, especially for follow-ups. Some clinics also connect patients with specialists through telehealth from their local clinic.
• Ask about outreach clinics. Some specialists travel to rural communities on certain days.
• Group appointments. Ask whether tests and visits can be scheduled on the same day.
• Ask about travel and lodging help. Some hospitals, health plans, and community organizations offer help with transportation or lodging. Medicaid covers rides to medical appointments in many situations.
• Prepare well. Bring your questions, medicine list, and records so you can make the most of the visit.

Your primary care provider still matters

Even when you see a specialist, your primary care provider plays an important role. They can help you understand what the specialist said, keep track of all your medicines, and coordinate your care. Let them know about any visits, tests, or new medicines from other providers.

When to talk with a healthcare professional

Talk with your primary care provider if:

• You think you might need specialty care
• You were referred but are having trouble getting an appointment
• Distance or cost is making it hard to follow through on a referral
• You are unsure what the specialist recommended

If your symptoms get worse while you are waiting for a specialist appointment, contact your primary care provider. In an emergency, call 911.

This page is for general education and does not replace advice from a healthcare professional.