Two different questions
“Do I need a referral?” is really two questions:
- Will the practice see me without one? Many scleral lens practices accept patients who call on their own. Some specialty centers and hospital programs ask for a referral, or at least records from your current eye doctor, before they’ll book you.
- Will my insurance pay without one? That depends on your plan, not the practice.
Ask both before you book.
When your plan needs a referral
A referral is a written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need one before you can get care from anyone other than your primary care doctor, and if you don’t get it first, the plan may not pay.[1] HMOs also usually limit coverage to doctors who work for or contract with the plan.[2] PPO plans generally let you see providers outside the network for an additional cost.[3]
For Medicare, in most cases you don’t need a referral to see a specialist under Original Medicare, while Medicare Advantage plans may require one.[4]
Plans for military families and veterans have their own referral and authorization routes. See does TRICARE cover scleral lenses? and does the VA cover scleral lenses? Medicaid rules vary by state; see Medicaid and scleral lenses.
Remember that scleral lenses can fall under a medical plan, a vision plan, or neither, and each may have its own rules. See medical vs vision insurance.
Referral vs prior authorization
These get confused. A referral gets you to the specialist. Prior authorization is the plan agreeing in advance that a particular service or item, often the lenses themselves, is medically necessary. Many plans require it for medically necessary contact lenses, and the fitter’s office usually submits it with your records. See prior authorization for scleral lenses.
Why a referral can help even when it isn’t required
- Faster intake. A note from your cornea specialist or eye doctor with your diagnosis and history saves the fitter time and repeated tests.
- Coverage. A documented diagnosis from a specialist supports a medical necessity claim. Wearers often say a cornea specialist’s referral helped their insurance approval.
- Shared care. When your doctors know each other, it’s easier to coordinate follow-up, especially after surgery or a transplant.
What wearers say
Many wearers booked directly with a specialty contact lens practice and never needed a referral. Others in HMO-style or military plans describe having to go back for a referral, or for a new one when the first ran out mid-fitting. People who went to specialty centers often describe an intake step first: records from their current doctor and a list of treatments already tried.
What to ask
Ask the practice:
- Do you see patients without a referral?
- Do you need my records before the first visit? Where should they be sent?
- Will you check whether my plan needs a referral or prior authorization?
Ask your plan:
- Do I need a referral to see a specialist for this? From whom?
- How many visits, or how long, does a referral cover?
- Do medically necessary contact lenses need prior authorization?
- Is this practice in network for my medical plan, my vision plan, or both?
What to bring, referral or not
- Your diagnosis and recent notes from your eye doctor or cornea specialist
- Surgery or transplant reports, if any
- Your current glasses and contact lens prescriptions, and the lenses themselves
- A list of your eye drops and other medicines
- Both insurance cards, medical and vision
See how to prepare for your first scleral lens appointment for the full list.
Finding a practice
For where to look and how to choose, see how do I find a good scleral lens specialist? and what to ask before booking a fitting.
Common questions
Can I book a scleral lens fitting without seeing another doctor first?
Often, yes. Many practices accept self-referred patients. Ask when you call, and check with your insurance plan, since some plans won't pay for specialist care without a referral.
What's the difference between a referral and prior authorization?
A referral is a written order from your primary doctor for you to see a specialist. Prior authorization is your plan agreeing in advance that a specific service or item, such as the lenses, is medically necessary. You may need one, both, or neither.
Does Medicare require a referral for scleral lenses?
With Original Medicare, in most cases you don't need a referral to see a specialist. Medicare Advantage plans may require one. Whether the lenses are covered is a separate question; see our Medicare page.
Do PROSE centers and other specialty programs need a referral?
Some do. Wearers describe intake processes that start with records from your current eye doctor and questions about the treatments you've tried. Ask the center what it needs before you call your doctor.
Who should write the referral?
Whoever your plan requires, usually your primary care doctor in an HMO. For the practice's own intake, a referral from your cornea specialist or current eye doctor, with your diagnosis and records, is most useful.
My referral expired during the fitting. What now?
Fittings can take several months, and some referrals cover a limited number of visits or time. Ask the practice to check your referral's limits at the start, and request a renewal before it runs out.