Do I need a referral for wound care?

Two questions hiding in one

Do I need a referral for wound care? The answer has two parts, because the question means two different things.

To contact Gateway, no. Patients, family members and caregivers in Greater St. Louis and the Metro East can call us directly, with or without a referral.

For your plan to pay, maybe. Some insurance plans require a referral from your primary care clinician before a visit with another clinician. That rule belongs to the plan, and only the plan can tell you whether it applies to you.

Calling for yourself or a family member

Asking for care on your own is sometimes called self-referral. You do not need a form from a doctor to start. Call 314-325-0126 or use the request care form, which asks only for a name and phone number.

When we call back, we ask where the patient lives, what kind of wound it is in general terms, and who is already involved in the person’s care. Then we check whether visits are available at that location.

Referral, order and prior authorization

These three words get mixed up, and each one means something different.

• Referral. One clinician, often your primary care clinician, directs you to another for a particular problem. Some plans want a referral on file before the visit.
• Order. A clinician’s written instruction for a specific service or item, such as home health nursing, dressings, equipment or a test.
• Prior authorization. The plan’s own approval before certain services or items are provided. See understanding prior authorization for wound care.

You might need none of these, one of them or all three, depending on your plan and the care the clinician recommends.

How plan type can affect referral rules

Plans differ, so treat these points as a starting place for your questions, not as a statement of what your plan requires.

• Original Medicare generally does not require a referral to see a specialist. Other Medicare rules still apply. See Medicare and wound care questions to ask.
• Medicare Advantage plans set their own rules. Some require you to choose a primary care clinician who makes referrals, and some do not. See Medicare Advantage and wound care questions.
• Medicaid rules depend on your state and on whether you are in a managed care plan. See Medicaid and wound care questions.
• Commercial and employer plans vary widely. Plans built around a primary care clinician are more likely to require referrals.

Questions to ask your plan and the treating practice

Call the member services number on your insurance card and ask:

1. Does my plan require a referral for wound care visits, including visits at home?
2. If so, who has to write it, and how does it reach the treating practice?
3. Does a referral cover a set number of visits or a set period of time?
4. Is a new referral needed if the care setting changes, for example from a clinic to home?

Then ask the treating practice whether it needs a referral on file before the first visit, and whether its office will request one from your doctor. The insurance page has more questions about coverage.

When an order is needed even without a referral

A plan with no referral rule may still need a clinician’s order for parts of your care. Home health nursing, for example, starts with an order from a physician or another clinician allowed to write one. Dressings and equipment sent by a supplier usually need an order as well.

The treating wound clinician can write orders for the wound care they direct. Gateway coordinates those orders with the agency or supplier, which is part of wound care coordination.

If your doctor or hospital sends the referral

Many people reach Gateway through a professional. A primary care office, surgeon, podiatrist, home health nurse or hospital discharge planner can use the refer a patient page or fax records to 314-786-7966.

If someone is referring you, ask them to include recent notes, the current wound orders and your medication list. Those records help the first visit most.

Keep your primary care clinician informed

Even when no referral is required, tell your primary care clinician that you are getting wound care. They manage conditions that affect healing, such as diabetes, circulation problems and swelling. With your permission, Gateway shares updates with that office.

Common questions

Related pages

• Request care
• Insurance and coverage
• Prior authorization explained
• How mobile wound care visits work
• Wound care records to gather
• Mobile wound care at home
• Medicare and wound care questions
• Medicare Advantage and wound care