In plain English
It means the member's primary care provider must send the member for that specific care. The plan ties coverage for the named service, provider, or specialist care to having that referral.
In context
Here, it reports that the plan requires a referral from the member's primary care provider for coverage of that provider or service.
- Situation
- Checking provider networks, authorization, referrals, eligibility, and preapproval states
- What it communicates
- reports that the plan applies a referral requirement for using the provider or service.
Meaning limits
By itself, this status does not say whether coverage will apply in a particular case.
Examples
“Under her plan, the rheumatology visit was referral required, so her primary care provider sent her to that specialist.”
“The plan marked the sleep clinic referral required.”