The receiving office reads a referral with three questions in mind. Who is this patient? What exactly are we being asked to do? How soon? A form that answers all three on the first page gets scheduled. One that says "eval and treat" with no history tends to wait in the fax queue until somebody phones.
The form has an insurance job as well. Some plans, most often HMOs, pay for a specialist visit only when the primary care provider's referral is on file before the date of service. When it's missing, the claim can come back with claim adjustment reason code 288, "Referral absent", often seen on remittances as CO-288.
Referral, consultation or prior authorization?
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| Take over part of the patient's care, such as treating one condition | |
| An opinion sent back, while the referring provider keeps managing the patient | |
| A record that the primary care provider approved the specialist visit, so the plan pays for it | The health plan, often through its portal |
| Approval of a specific service before it's done | |
The last two get confused, and payers deny them with different codes. A missing plan referral is CARC 288. A missing prior authorization is CARC 197, "Precertification/authorization/notification/pre‑treatment absent". Both descriptions are from the X12 claim adjustment reason code list.
What each section holds
- Patient: name, date of birth, phone, preferred language and any access needs.
- Insurance: plan name, member ID, plan referral or authorization number, visits approved and the dates the referral is valid.
- Referring provider: name, NPI, practice, phone, fax and a secure email or portal address.
- Receiving provider: a named clinician if you have one, otherwise the specialty and location.
- Reason for referral: the specific question, in one or two sentences.
- Urgency: routine, within a set number of days, or urgent, with a phone call for anything urgent.
- Diagnosis or symptom codes, at the level of certainty you actually have.
- Relevant history: active problems, medications, allergies and what has been tried.
- Attachments: the latest relevant note, labs, imaging reports or scores.
- Patient informed: whether the patient knows about the referral and agrees.
- Report back: how and when you want the specialist's findings.
A primary care physician refers Dana Ruiz (fictional), 52, to sleep medicine. Her husband reports loud snoring and pauses in her breathing at night, and she nodded off at a red light twice this month. Her Epworth Sleepiness Scale score is 15. Her insurance is an HMO plan that requires a referral for specialist visits.
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| Dana Ruiz, date of birth March 14, 1974. Prefers text reminders. Speaks Spanish and English. |
| HMO plan, member ID on file. Plan referral entered in the portal: 3 visits, valid October 15, 2026 to January 13, 2027. |
| Primary care physician, with NPI, office phone, fax and portal address |
| Sleep medicine, in network, within 30 minutes of home |
| Please evaluate for obstructive sleep apnea and arrange a sleep study if you agree it's indicated. |
| Within 2 weeks, because of drowsy driving. Office called the sleep clinic on October 15. Patient advised not to drive when sleepy until seen. |
| R06.83, snoring. R53.83, other fatigue. |
| Hypertension, treated with lisinopril. BMI 33. No known drug allergies. No previous sleep study. |
| Last office note, home blood pressure log, Epworth score sheet |
| Yes. Agrees, and asked for an early morning appointment. |
| Sleep study results and treatment plan by portal message |
The codes are the symptoms, not G47.33, obstructive sleep apnea. For outpatient encounters, the FY2027 ICD-10-CM Official Guidelines (Section IV.H) say not to code a diagnosis documented as probable, suspected or rule‑out, and to code the signs and symptoms instead. G47.33 belongs on the record once a sleep study confirms it.
- Date of referral:
- Patient name, date of birth, phone, preferred language, access needs:
- Insurance plan and member ID:
- Plan referral or authorization number, visits approved, valid from and to:
- Referring provider, NPI, phone, fax, secure email:
- Referred to (name or specialty, location):
- Reason for referral and the specific question:
- Urgency: routine / within ___ days / urgent (phoned on ___):
- Diagnosis or symptom codes:
- Active problems, medications, allergies:
- What has been tried so far:
- Records attached:
- Patient informed and agrees: yes / no
- How to send findings back:
- Referring provider signature and date:
Avoiding referral denials
Check these before the specialist visit:
- The plan's referral is entered in the plan's own system. A fax to the specialist doesn't count.
- The date of service falls inside the referral's valid dates.
- Visits used so far are within the number approved. A fourth visit on a three-visit referral needs a new one.
- If the plan ties the referral to a named specialist, that specialist is the one who sees the patient.
- Anything the plan also requires prior authorization for has its own approval number.
The CO-288 page covers how to correct and resubmit when a denial gets through anyway.
Common mistakes
- No question. "Please see" leaves the specialist guessing what you want from them.
- Urgency left blank, so an urgent referral waits in the routine queue.
- Sending the whole chart. The specialist needs the latest relevant note and results, not ten years of visits.
- Not telling the patient. Someone who doesn't know a referral went out won't be expecting the scheduling call.
- No tracking. Keep a referral log and check after two weeks whether an appointment was booked.
- Coding a suspected diagnosis as confirmed. It follows the patient into the specialist's records and onto the claim.
HIPAA and sending a referral
Referring a patient counts as treatment under HIPAA. The definition of treatment in 45 CFR 164.501 includes "the referral of a patient for health care from one health care provider to another", and 45 CFR 164.506(c) lets a provider disclose information for another provider's treatment without the patient's authorization.
The minimum necessary standard doesn't apply to disclosures to a provider for treatment, under 45 CFR 164.502(b)(2). A focused packet is still the better referral, because the specialist finds the answer faster. Records from federally assisted substance use disorder programs are an exception, with consent rules under 42 CFR Part 2, and some state laws add limits of their own.
Writing referrals with Twofold
Twofold can hold this layout as a custom template. Dictate the reason, urgency and history after the visit, and Twofold drafts the form in these fields. You check the codes and the question before it's sent.
The mental health referral form template covers referrals to and from therapists and psychiatrists. For the paperwork around a referral, see the medical release form, the insurance verification form and the medical history form. When care is handed over at the end of a hospital stay, a discharge summary does the job of the referral letter.
Reviewed and updated October 2026.
