Yale Health

Frequently Asked Questions

How are referrals approved?

The referral may be generated and approved within the department. Some referrals require further medical review. These referrals are pended for review by the Referrals Department. If the referral is pended, the referral is reviewed and additional information may be needed prior to approval.

How do I get a referral to an outside clinician or service?

You must contact your primary care clinician (PCC) department.  Your PCC can order these services if they are needed and submit a referral request for approval.

Is there a time limit on referrals?

Yes.  The time period and services authorized are communicated to the provider to whom you are referred.  You can contact the Referrals Department for a copy of your authorization with details.

What happens if the consultant I am referred to recommends that I see another non-Yale Health clinician?

A referral covers only the specific services requested on the form by your Yale Health clinician. If the outside clinician feels you need additional consultations, treatments, or testing, that clinician must contact the referring Yale Health clinician to have a new referral generated for additional services. Your Yale Health clinician can order these services if they are needed and submit a referral request for approval. Make sure to check with your clinician or the Referrals Department at 203-432-7397 to assure that another referral has been approved before additional services are rendered.

Do I need a referral for Specialty Services?

Yes. Referrals to the Specialty Services Department are for a specific problem identified by a primary care clinician (PCC).  Routine, non-emergency appointments are typically scheduled within four weeks.

I am a student. When do I need a referral?

You do not need a referral to use a primary care clinician (including those in the Ob/Gyn and Athletic Medicine Departments) or to use the Acute Care or Mental Health & Counseling Departments. Some services available to you under Yale Health Basic coverage do require a referral from your primary care clinician. These include nutritional counseling and laboratory services.

You need an in-house referral if your primary care clinician refers you to specialist within 55 Lock Street. If you are are referred outside of 55 Lock Street for any services—office visits, treatments, tests, consultations—you need an outpatient referral.

No referrals are needed for the use of fee-for-service departments.

Do I need a referral to get a mammogram?

Yale Health members do not need referrals for screening mammograms and may call The Breast Center at Smilow Cancer Hospital at Yale-New Haven directly at 203-688-1010 to schedule an appointment. However, please give the mammography center your primary care clinician's or Ob/Gyn clinician's name so your results can be forwarded to them.  If Yale Health is not your primary insurance, please verify coverage and the need for a referral with your primary insurance company.         

All other breast imaging requires a referral.

What type of issues would generate a referral to the nutritionist?

Nutrition consultations are appropriate for those who would benefit from individualization of diet recommendations due to medical concerns. Examples of this are people who have:

  • high blood sugar;
  • diabetes;
  • high cholesterol;
  • high triglycerides;
  • high blood pressure;
  • or who are obese.

I am a Yale Health member. Does my PCC need to refer me to a mental health provider?

No.  Yale Health members may call Magellan directly at 800-327-9240, TDD 800-456-4006 to access mental health/behavioral health services. 

I have Yale Health Hospitalization/Specialty Care coverage. When I saw my primary care clinician we discussed a treatment that might be helpful. I obtained the treatment, paid the bill, and submitted it to Yale Health, but the claim was denied. Why?

Although your clinician may have discussed a treatment, you must receive a referral and have prior approval in order for the treatment to be covered. If you obtain treatment without a referral and prior approval, the claim will not be paid. The same applies if you want a second opinion.

I was referred to an outside Ophthalmology/Optometry provider. Can I just keep seeing this person?

No.  When referred out to another provider, you must come back to Yale Health for follow up care.