What is a Referral Requirement?

A referral requirement is an insurance plan rule that requires you to obtain authorization from your primary care physician before seeing a specialist or receiving certain medical services. This requirement is common in HMO and some POS plans, where the primary care physician acts as a gatekeeper to coordinate care and control costs. Without proper referrals, the insurance plan may not cover specialist visits or procedures.

Why referral requirements matter

• Coordinates patient care: Ensures primary care physicians oversee overall treatment plans
• Controls healthcare costs: Reduces unnecessary specialist visits and duplicate services
• Affects access timing: May delay specialist care while waiting for referral approval

How Solace can help

A Solace advocate can help you understand your plan's referral requirements, expedite referral processes for urgent needs, and resolve issues when referrals are delayed or denied. Advocates can also assist with appeals if services are performed without required referrals.