Health Insurance Guides
What are the different types of referrals to a specialist and how do they work?
Key takeaways: What are the different types of referrals to a specialist and how do they work?
If you’re using private medical insurance for treatment, it’s important to know which type of specialist referral to ask your GP for.
With ‘named’ referrals, your GP refers you to a specialist, so you choose who you see. If the specialist is not on your insurer’s list, they may not cover any or all of their fees.
With ‘open’ referrals, your GP doesn’t give you a name, but instead tells you the type of specialist you need – for example, a dermatologist. This may allow your health insurer to source a specialist for you, which will normally mean they’ll cover the specialist’s fees.
With some health insurance plans, you need to ask for an open referral for your insurance to cover your treatment.
What's in this article
Jump to sections:
- What are the different types of specialist referrals and how do they work?
- Which type of specialist referral is right for me?
- Do I need to contact my health insurer before getting a referral? And what do I need from my GP?
- What about if I’m being referred for a test, rather than to see a specialist?
- How do I know which specialist to see?
- Can I see a private GP to get my referral, or does it have to be my NHS GP?
- Do I make the appointment with the specialist, or does my insurer do this?
- What happens if I need further treatment after my referral?
- Why would I need an open referral for my insurance to cover the treatment?
- Do I always have to have a GP referral to see a specialist?
What are the different types of specialist referrals and how do they work?
If you want to use your private health insurance for treatment, it’s important to check which kind of specialist referral you need for your insurance to cover the costs.
A specialist referral is when your GP thinks you need a specialist (consultant) to review you and decide on the next steps for your treatment. GPs can make two kinds of referral: an ‘open’ referral or a ‘named’ referral. Health insurers may prefer or require you to have an ‘open’ referral.
Which type of specialist referral is right for me?
Whichever type of referral you go for, you’ll still need to contact your health insurer before arranging treatment, so they can check that your insurance covers your condition and treatment for it.
Open referral: “You need to see a dermatologist”
Your GP refers you to a type of specialist (a specialty), but doesn’t name a particular specialist. For example, they may say you need to see a dermatologist.
An open referral can be helpful if:
- you don’t know any local specialists and are happy for your insurer to source one for you
- your GP doesn’t have a recommendation
- you want to be certain that your health insurer will cover your specialist's fees in full.
With some health insurance plans, you must ask for an open referral for your plan to cover the cost.
Named referral: “You need to see Dr Davis”
Your GP refers you to a particular specialist.
A named referral can be helpful if:
- you know which specialist you want to see – for example, you’ve researched them and know they specialise in your condition
- you’ve seen the specialist previously and want to continue with them
- your GP recommends them
- you’re happy to check with your insurer whether they’ll pay the specialist’s fees in full, and make up the difference if they don’t.
However, you’ll need to contact your health insurer to make sure the specialist is on their list, and confirm whether your plan will cover all of their fees, or only part of them.
If your health insurer doesn’t cover the specialist’s fees in full, you can still see the specialist, but you’ll need to pay some or all of the fees yourself. This may be expensive.
Do I need to contact my health insurer before getting a referral? And what do I need from my GP?
You may not need to contact your health insurer before seeing your GP – but it’s best to check your policy documents for any rules to do with existing health conditions or types of referral.
Contact your health insurer as soon as your GP says you need a referral.
Here are the steps to take with your GP and health insurer for your referral:
- Check your policy documents to see if you need a particular type of referral and if the treatment is covered.
- Ask your GP for a private open or named referral. Ask for a referral letter.
- If they give you a referral, contact your health insurer to double check the treatment is covered. They’ll give you a claim number or pre-authorisation code that you’ll need to give to the specialist or hospital, and tell you if you need to pay anything.
- Arrange your treatment.
Depending on how your plan works, your health insurer may also contact your GP to check your medical history. This is so they can check when your symptoms started, because some plans won’t cover you for symptoms or conditions you had before your health insurance started. If your health insurer asks your GP to fill in a form, your GP may charge you for this. Your health insurer may not cover the cost of this.
What about if I’m being referred for a test, rather than to see a specialist?
If your GP thinks you need a test, such as a scan or camera test (endoscopy), check with your insurer about whether you need a specialist referral first, as some insurers will need this. This is slightly different to how referrals can work in the NHS, where the GP can refer you directly for some tests without seeing a specialist first.
How do I know which specialist to see?
You can check for local private specialists at The Private Healthcare Information Network. This is an independent, impartial service that publishes information about the safety, quality and costs of private healthcare.
Your GP might also be able to recommend a specialist.
Can I see a private GP to get my referral, or does it have to be my NHS GP?
Your NHS GP can refer you to any specialist, NHS or private.
If you see a private GP, including your health insurer’s GP service, you’ll need to check with your insurer whether the GP can refer you directly to a private specialist. Many insurers will accept a private GP’s referral, especially if it’s their own service, but may have rules about this. Your NHS GP may need to complete any medical forms.
Do I make the appointment with the specialist, or does my insurer do this?
Your insurer may be able to book your appointment for you, especially if you have an open referral. However, normally you'll need to book the appointment yourself.
What happens if I need further treatment after my referral?
If your specialist says you need follow up tests or treatment, including surgery, you’ll need to tell your health insurer so they can confirm that you’re covered and give you authorisation.
Why would I need an open referral for my insurance to cover the treatment?
Some health insurers offer an option where they source a specialist, or a few specialists to choose from, for you. This limits your choice, but can reduce your premiums. This is because your insurer will have agreed costs with the specialists they source.
Check your policy documents before seeing your GP, so you know which type of referral to ask for.
Do I always have to have a GP referral to see a specialist?
Whilst normally you'll need a GP referral, some health insurers may offer you direct access to a specialist for some conditions, without needing to see a GP first for example for musculoskeletal issues. Check your policy documents to see if this applies to your plan.