Referrals are necessary in order to preserve the primary care practitioner’s Gatekeeper relationship with the patient.  Referrals allow the primary care practitioner to approve specialty services for members on their panel.  Referral Forms are not required for submission to the specialist or Gateway.  However, notification to the specialist is necessary, but can be made verbally or through a script given to the patient.  Don’t forget to document the referral in the patient’s medical record including the number of visits or length of time of each referral.

Referrals must be made to an in-network Gateway specialist. Only under special circumstances can a primary care practitioner refer a member to an out-of-network provider. All out-of-network referrals require prior-authorization through Gateway’s Utilization Management Department. Authorization is not required for emergency services or renal dialysis services (when the member is temporarily outside the plan’s service area) provided by an out-of-network provider.