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Physician’s Referral vs. Insurance Authorization

You injured your elbow in a golf shot gone bad or a terrible fall! Due to the severity of the injury, your primary care physician refers you to a specialist, an orthopedic surgeon who specializes in upper extremity injuries, such as the physicians at Hand to Shoulder Center of Wisconsin. Your first thought is that you will do whatever it takes to fix your elbow and stop the pain and discomfort. Your next thought may be; does my insurance cover a specialist visit?

What is the difference between a physician’s referral vs. an insurance authorization?

A physician’s referral is defined as: Your primary care physician (PCP) or urgent care/emergency department (ED) provides you with a verbal recommendation to see a specialist. Sometimes the PCP will write a referral or script that instructs you to follow-up with a specialist.

An insurance authorization is defined as: Your health insurance company authorizing or giving written approval (documented approval) for you to be seen by a specialist.

How do I get an insurance authorization?

The process is somewhat simple but may be intimidating because it is something we don’t do on a regular basis. Obtaining an authorization is important as it may be needed to protect you from incurring costly charges.

Follow these two easy steps!  Grab your insurance card and find the customer service number on the back of the card. Call the toll-free number and request that the representative check to see if your policy requires an authorization to be seen by a specialist. If it does not, you are good as gold. No need to research any further. If your policy requires an authorization, call your PCP and request that they contact your health insurance company to initiate the preauthorization process. If you are referred to a specialist by an ED clinician, your PCP may want to verify why you are requesting an authorization to see a specialist. Once this need is determined, your PCP can go to your insurance company’s preauthorization portal within their website and complete the request.

Your PCP will provide a brief description of the injury/condition and diagnoses codes to your insurance company along with the information on the specialist you are being referred to. It is then submitted for review and often times approved by the insurance company and faxed to the office of the specialist for their records.

What’s next?

When scheduling your appointment with the specialist, inquire if they received your authorization from your insurance company.  If they have not, contact your insurance company to see if they have authorized the visit. If they have no records of an authorization, call your PCP back to verify they have submitted the authorization request.

 The bottom line…

Know your health insurance policy requirements. If an authorization is needed to see a specialist, contact your PCP to start the ball rolling to get the best possible reimbursement on the charges.

If an authorization is not done prior to your initial visit to the specialist, your insurance company may not cover the expense of the visit nor will they back date an authorization. In other words, it will be the patient’s responsibility to pay the entire charge for the specialist visit.


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