Prior authorizations and physician referrals are occasionally interchangeable, yet these phrases are significantly distinct. A primary care physician (PCP) issues a referral for the patient to visit a specialist. In contrast, the payer (an insurance company) grants prior authorization to a medical practice or physician for the performance of medical service. In further detail, let’s examine the distinction between Specialty Clinic Referrals and prior authorization and how NEMB can help with such services.

Understanding Medical Referrals

According to, a referral refers to a written request from a patient’s primary care physician (PCP) to visit a specialist or receive specific medical treatments. A specialist is a physician who offers treatment for a particular ailment or body part. Numerous types of experts exist. Below are a few examples:

  • Cardiologists treat people with cardiac conditions.
  • Oncologists provide care for cancer sufferers
  • Orthopedists treat patients with bone, joint, or muscular conditions.

In several Health Maintenance Organizations (HMOs), a referral is necessary before a patient may get medical treatment from a doctor other than the primary care physician. Visiting a specialist without the consent of the primary care physician or visiting a specialist who is not certified by the insurance provider will lead to the patient being responsible for almost the whole treatment cost.

So how do referrals work? Generally, the patient must see a primary care physician (PCP). If the PCP feels that a specialist is necessary, they will refer the patient to a specialist and document the referral in the patient’s medical files. Referrals are often made in writing or may require a referral number which must populate the claim to the insurance. Some referrals must be on file with the patients insurance to match up with the claim when it is received. Most referrals have specific date ranges of validity. In sum, each payer can have different rules, all of which must be followed if the clinic expects payment. 

Understanding Prior Authorization Services

Prior authorization refers to a formal request issued by the medical practitioner (before providing a medical service) to the insurance provider for consent to continue medical treatment. Tests, procedures, medications, and other medical procedures may all need authorization. Prior authorization does not imply a promise of payment. It confirms that the payer will refund the medical expense under specified circumstances. These conditions could include:

The approved treatment from the Specialty Clinic Referrals must be done within a certain timeframe.

  • The physician may visit the patient several times within a certain time frame.
  • Approval is granted subject to the criteria mentioned at the approval time. (If the PCP advises further medical treatments, the medical practice must get a separate PA.)
  • Prior authorizations (PAs) include several parties, including patients, healthcare providers, and insurance companies.

A physician’s office or medical billing firm may get prior authorizations over the phone. It is essential, however, to maintain a written record that contains the authorization information, and the names of the approving representative from the payer’s office. For authorizations accepted via the payer’s site, saving a copy of the approval is essential. Without a documented authorization you risk losing reimbursement on the claim. 

Reasons Behind Denial Of Prior Authorizations

Whenever your insurance company informs you that it cannot cover the expense of your prescription or treatment, it refers to a denial. Specialty Clinic Referrals can face denial of prior authorizations due to several reasons. 

Frequent insurance rejection reasons include:

  1. Your present treatment is considered neither medically necessary nor suitable.
  2. The care is seen as experimental or exploratory
  3. Clerical mistakes in the initial documentation, such as typos or spelling mistakes, or data problems,
  4. The physician you visited was out-of-network.
  5. Your insurance has expired.
  6. The authorization was not requested and approved prior to services
  7. The insurance provider no longer covers you.

How Can NEMB Help Medical Professionals With Specialty Clinic Referrals?

At New England Medical Billing, our services cannot determine which insurance require referrals and authorizations. Referrals and authorizations are a clinical process that must be done prior to scheduling and services. Medical billing can assist by using edits to stop claims for payers known to require referrals or authorizations, setup system tools to manage referrals and authorizations, and notify the clinic as soon as denials are received so they can stop services until the situation is remedied. Thus, working together the clinic can ensure optimized workflows that identify potentially unpaid claims before they are submitted, saving you money and time. 

Understanding the intricacies of receiving pre-authorizations and referrals seems crucial for preventing lost income and severe financial effects on your business. New England Medical Billing provides the knowledge to assist you in managing what may be a difficult procedure. We improve the financial condition of your practice so that you and your team may concentrate on the well-being of your patients. Our objective is to enhance your medical physician’s bottom line dramatically.

So, contact us to know how we can help you with Specialty Clinic Referrals.


Need more information or have questions on any type of billing we do?

Affiliates of VSS Medical Technologies

Sign up for company updates and latest news from NEMB.

Get In Touch 


888 - 771 - 6115
508 - 297 - 2068

19 Norfolk Avenue
South Easton, MA 02375


©Copyright 2024 New England Medical Billing Group LTD. All rights reserved.