Your claim was denied because you had no referral. Here is what you can do.

Why was my claim denied for no referral?

A referral is a written order from your primary care doctor for you to see a specialist or get certain medical services. Healthcare.gov says many HMO plans require one before you can see anyone other than your primary care doctor, and that the plan may not cover care you get without it.

Sometimes the referral was needed and never sent. Sometimes it was sent and the plan lost it or entered it wrong. Your denial letter should say which reason the plan used, so read that line first.

Can my primary doctor write a referral after I already saw the specialist?

It is worth asking. Call your primary care office, explain that the claim was denied for no referral, and ask whether they can send one to the plan for that visit. Whether the plan accepts a late referral depends on the plan, so we cannot promise it, and the plan's own rules decide.

Ask the office to put the date of the visit and the denial claim number on the request, and keep a note of who you spoke to and when.

How long do I have to appeal a denial?

Healthcare.gov says you must file an internal appeal within 180 days (6 months) of getting the notice that your claim was denied. Do not wait for the referral question to settle first. Put the date on your calendar today.

Deadlines depend on your type of plan. Marketplace and many job-based plans follow the rule above, but Medicare, Medicaid and some other plans have their own appeal steps and deadlines. The deadline printed on your denial letter is the one to go by.

How do I appeal a no-referral denial?

You can appeal even if you are unsure you will win. Here are the basic steps. If you want help, healthcare.gov says the Consumer Assistance Program in your state can file an appeal for you.

• Step 1: Find the dates and numbers. Write down your claim number, member ID, the date of the visit, and the date on the denial letter.
• Step 2: Ask your primary doctor's office. Request a referral for that visit, or a letter from your doctor about why you needed the care.
• Step 3: File the internal appeal. Fill out your plan's appeal form, or write a letter with your name, claim number and health insurance ID number. Include the doctor's letter. Send it before the deadline on your denial letter.
• Step 4: Keep copies and follow up. Save everything you send and receive. Under the healthcare.gov rules, the plan must decide within 30 days for a service you have not received yet, or 60 days for one you already received. Your plan type may change these timelines.

What if my internal appeal is denied too?

You can ask for an external review. An independent reviewer, not your insurer, looks at the denial. Healthcare.gov says you generally must file within 4 months of the final denial notice, and your insurer is required by law to accept the reviewer's decision.

Cost depends on the process. Under the federal process run by HHS there is no charge, and under other processes the charge cannot be more than $25 per review. Medicare and Medicaid have their own separate appeal levels, so check your letter for the next step.

Does this apply to dental or non-HMO plans?

Referral rules differ a lot by plan type, and some dental plans have their own rules. Your plan documents and denial letter say which rules apply to you.

The appeal rights above come from healthcare.gov and mainly describe marketplace and similar health plans. Employer, Medicare, Medicaid and dental plans can have their own timelines, so check your letter. This page is general information, not legal or medical advice.

Your checklist

• Find the claim number and the date on the denial letter
• Write down the appeal deadline from your letter (180 days on many plans)
• Call your primary doctor's office and ask for a referral for that visit
• Ask the doctor for a short letter about why you needed the care
• Send the plan your appeal and keep copies of everything
• Note who you talked to, and when
• If denied again, ask for an external review (within 4 months on many plans)

A letter you can copy

[Date] [Plan name] Appeals Department [Plan address] Re: Appeal of denied claim Member name: [Your name] Member ID: [ID number] Claim number: [Claim number] Date of service: [Date of visit] Date of denial notice: [Date on letter] To whom it may concern, I am appealing the denial of the claim above. The reason given was that no referral was on file. [Dr. name] is my primary care doctor, and [he/she/they] [referred me / has been asked to provide a referral] for this care. A letter from my doctor is enclosed. Please review this appeal and send me your decision in writing. If you need anything else from me, contact me at [phone or email]. Sincerely, [Your name] [Your address]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• Denied because the insurer says you have other insurance
• Your claim was denied as "not covered" or excluded. Is that the end?
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.