Primary care doctor referrals explained

Many insurance companies require referrals from a primary doctor to visit any specialist. You must understand this beforehand by studying and understanding your policy. Dr. Walters with Platinum Care LA adds, “If you do not receive referral from a primary doctor, your insurance company may even deny your claim.” Therefore, if you need referral try to get it in advance.

So, what is referral?

Well, it’s an authorization from a doctor that says that a particular line of treatment is medically necessary. Pre authorization or pre-approval in time makes you eligible for payments from your insurance company. The best way to understand if you need pre-approval is to ask your insurance company about that. However, at this stage you can keep other questions in your mind, such as number of visits you’re entitled to, and whether approval is required for each and every visit. If you need to be in inpatient care or need to be hospitalized, how many days you’ll be allowed to stay? A referral from a doctor actually satisfies the insurance company that you actually need the treatment from a specialist for your medical condition.

In Network Providers

Usually, “in network” providers are much cheaper than “out of network” assistance providers. So whether you want to save some money or want to visit a doctor you prefer will be a choice you will have to make. Most insurance providers may not have a flat difference. Dr. Walters comments, “For some, seeing their “in network provider” may cost you a $30 co-pay, whereas “out of network provider” may cost $40. Others may cost you $30 and “out of network provider” may cost you 30% – which can be much higher than $30.”

Number of Visits

Based on your state and your plan, it’s not uncommon to have limits on doctor visits. If you exceed the limit, you may have to pay from your own pocket. Moreover, insurance providers may not include some diagnosis in all their policies. If you’ve applied by disclosing your condition, they may not offer you any cover for that. In fact, your chosen company may provide you a comprehensive list of uncovered and covered diagnosis.

It’s important to understand all that’s included in your policy and if you’ve trouble understanding that, see if someone from your employer, doctor’s office, or a trusted friend, can assist you in getting the right information.

If you got your health insurance from your company, you can contact their HR department. If company is large, contact their dedicated business specialist for help. If you work for a smaller company, you can talk to the person who will arrange the health care.