What is a medical referral?

Many patients are familiar with referrals from their GP (Hausarzt/Allgemeinarzt). The most common example is a referral to a specialist for further examinations.

Strictly speaking, a medical referral is a form used by a community-based doctor who is authorised to bill Public Health Insurance (Gesetzliche Krankenversicherung (GKV)). It is used to refer a patient to another doctor in a different specialty for further diagnostics, a second opinion, or treatment. In rare cases, a patient may also be referred to a doctor of the same specialty.(1)

The referral includes the suspected diagnosis, the findings collected so far, previous treatment attempts, and the exact clinical question or specific request that the referring doctor is asking the specialist to address.(1)

Conversely, with the patient’s consent, the specialist provides feedback on the examination, diagnosis, and treatment recommendations to the referring doctor.(1)

In this way, referrals streamline communication between doctors and are intended to reduce costs caused by unnecessary or duplicate examinations.(1)

The referring doctor must indicate on the referral form whether it is issued for curative or preventive treatment. “Curative” means “aimed at healing”, while “preventive” focuses on the prevention and early detection of illnesses and complications.(2,3,7)

When do you need a referral?

In general, the Public Health Insurance (GKV) expects patients to see their GP first when they have symptoms and then get a referral to a specialist when required.

However, if you are not enrolled in a so-called “GP-centered care model” (Hausarztmodell) with your health insurance, you are able to see most specialists without a referral.

There are some exceptions; for some specialists a referral is always required.

These include specialists in:

Laboratory medicine
Microbiology and infectious disease epidemiology
Nuclear medicine
Pathology
Radiology
Radiotherapy
Transfusion medicine

For these specialities, services can only be billed through public health insurance if the patient has a prior referral.(1)

For all other specialists, for example orthopaedic specialists, ophthalmologists, gynaecologists and paediatricians you do not need a referral.(1,5,6)

What is the GP-centred care model (Hausarztmodell)?

Public health insurance providers are required by law to offer their members GP-centred care models, a requirement through which the legislator hopes to achieve savings in the healthcare system.(4,5)

Within the GP-centred care model, patients must always see their GP first when experiencing symptoms and if necessary their GP will then provide a referral to a specialist.(5,6)

Essentially the model is designed to benefit patients: diagnosis and treatment of an illness are coordinated by the GP, and patients receive additional services from their health insurance, such as vaccination reminders or special preventive care services.(6) In addition, GPs participating in the programme are required to complete regular educational training.(6)

What does a referral include ?

The referral form includes your name, your date of birth, the name of your health insurance provider and your insurance number.(7) The referring doctor indicates whether the referral is for curative or preventive care.(7)

In addition, the following information is noted(7):

The quarter in which it was issued
Whether it relates to an accident or consequences of an accident
The date of an outpatient operation in connection with the referral
Your sex
Which medical speciality the referral is for
The purpose of the referral: The referring doctor can request an examination (Auftragsleistung), request a second opinion (Konsiliaruntersuchung), or refer the patient for joint and ongoing treatment.
The date until which the referring doctor has signed the patient off sick
Previous examinations, suspected diagnoses, and the course of treatment so far

In short, the referral contains information about you and your illness, the medical speciality you are being referred to, and the type of care requested.(7)

How long is a referral valid for?

There’s a persistent rumour that referrals are only valid in the quarter in which they were issued.

However, this is not correct:

A referral is also valid in the following quarter, as long as the patient can present a valid health insurance card to confirm active membership of Public Health Insurance (GKV).(8)

Even if your treatment with the specialist you’ve been referred to continues beyond one quarter, you don’t need to submit a new referral at the start of the next quarter.(9)

Does a referral help you get a specialist appointment faster?

Whether you get an appointment faster depends on the type of referral you have. Since the introduction of the Act for Faster Appointments and Better Care (Terminservice- und Versorgungsgesetz), GPs can issue an “urgency code” (Dringlichkeitscode) with the referral if treatment with the specialist should take place promptly.(10)

Good to know:

With an urgency code, patients can contact the appointment scheduling service (Terminservicestelle) online or by telephone to get a specialist appointment within 35 days.(11)

If the appointment scheduling service considers the case urgent, an appointment for the following day will be arranged.(12)

You can book appointments through the appointment scheduling service without an urgency code for certain specialties (e.g., GP, gynecology, pediatrics, ophthalmology, an initial psychotherapy consultation). For most other specialists, an urgency code is required.(15)

The information provided is for general information only and must not be used as a substitute for a medical diagnosis or treatment by a doctor. Self-diagnosis and self-treatment are strongly discouraged.