Referral Tips: Your HMO and the Yale Medical Group

As more and more of us choose HMOs or managed care plans, it is helpful to be aware of the specific referral requirements used by your insurance company. For most managed care plans, referrals are required for visits to specialists and for certain tests and procedures.

The Yale Medical Group recognizes the importance of following the referral process as part of your care. The following questions and answers offer guidelines to simplify the referral process when visiting your Yale physician.

Click on the questions listed here or browse through this section:

• Why do I need a referral to a Yale specialist?
• What is my role, as a patient, in the referral process?
• How can I be sure if I need a referral for services at Yale?
• What happens if I do not have a referral before I see a Yale specialist?
• What if my Yale specialist refers me to another specialist?

Click here to review HMO referral terminology.

Why do I need a referral to a Yale specialist?

Many HMOs and managed care plans use the gatekeeper approach to track the use of specialist services, tests, and treatments. In these plans, the primary care physician is responsible for obtaining approval for the referral. It is important that you and your doctor are aware of your insurance company’s referral rules.

What is my role, as a patient, in the referral process?

As a patient, you can make sure that your referral to a Yale specialist is complete and approved by your health plan before your visit. When your primary care physician sends you to a specialist or orders special studies or treatments, ask your doctor if a referral is required. Once you are under a specialist’s care, it is important to check from time-to-time to make sure that your referral is still valid. Some HMOs set a specific date when the referral expires or may specify the number of visits allowed. It is also important to review your health plan’s member services guide section on the referral process.

How can I be sure if I need a referral for services at Yale?

There are a couple of ways for you to check on your health plan’s referral rules as outlined here:

• Check your health plan’s member guide or call the member services department.
• Ask your primary care physician about your HMO or health plan’s referral rules before you schedule an appointment.
  

What happens if I do not have a referral before I see a Yale specialist?

There are several problems that could arise if your referral is not completed before you receive services at Yale. While health plan rules vary, here is a sample of what may happen:

• Your appointment with the specialist or service may be delayed until the referral is made.
• For some health plans, you may be responsible for payment of the bill.
  

What if my Yale specialist refers me to another specialist?

Some HMOs that require a referral from your primary care physician to see a specialist apply this same rule for specialist-to-specialist referrals. This means that only your primary care physician can make a referral to another specialist. If your Yale physician needs to refer you to another specialist, you should check first with your health plan to see if the referral must come from your primary care physician.