REFERRALS
What is a referral?
A referral is issued by a primary care physician (PCP) for the patient to see a specialist.
Done to clear Diagnosis hard stop
Enter Diagnosis in Epic
First step before submitting an authorization.
Check if physician is on the intake list
CT Chest W Contrast with Mesothelioma diagnosis
CT Chest WO Contrast per protocol.
Where do you find clinicals?
Chart Review
UHC Community Medicaid Referral Requirements
Referral Required
How to fix Referral Expired Status
Check Authorization tab and make sure the expiration date is 1 year from the start date, and the IBNR is 1 year from the expiration date.
BCBS Medicare HMO: Mammogram
Auth Required True or False
True
CT Brain/ Head Imaging protocol
Either W/ & W/O contrast or W/O contrast , NEVER only W/contrast
Places to find Physician Office Notes
Encounters, Notes, Physician Order, Media
Referrals (Plans) that act as an authorization
Humana Medicare HMO, Careplus Medicare, Freedom Medicare/Optimum
Sunshine Medicaid Follow up: Auth denied due to a lack of clinicals. What do you do?
Resubmit auth notating Clinicals weren't submitted on NIA
How to submit clincials for AIM
Fax them
CT ABD PELV W Con Diagnosis Calculus of Kidney. Does it meet the contrast protocol?
NO, the test has to be changed to CT ABD PELV WO Con
CT Angio Heart minimum data set
Physician notes, Imaging, EKG, Stress Test, Echo
Where do we find the PCP information?
Experian
Assigning accounts to Designated IC
M-W 0-2 days
Thurs-Fri 0-4 days
Auth submitted but test does not follow imaging contrast protocol, what should you do?
Call the insurance portal and update the CPT code (unless the pt has an allergy)
CT ABD PELV W Con Diagnosis Renal Cancer. Does the test meet the imaging contrast protocol? Why or why not?
NO, Renal cancer should be WO contrast
Clinicals that can act as a second physican note if the ordering physicain only have one note on file?
Relevant ED Visit and physician note for different dr thats relevant
Ordering physician is APRN and works with Tarek Mekhail MD. BCBS Referral is on file for Tarek Mekhail.
How do you work the account?
Submit authorization under MD, no need to request a referral for APRN
Requirements for calling patients
Calling on a recorded line
Verify 2 patient identifiers
Auth approved for Advent Health Imaging. Can we use the auth, why or why not?
No. We need to check Epic to see if the auth was used. If it wasn't used we need to call the insurance portal and update the facility to Advent heath
Does the test meet the imaging contrast protocol? MRI Arthogram W Contrast
Yes
Scenario: Auth Pending, CT Chest W Contrast Diagnosis Breast Cancer, Ordering physician Tarek Mekhail.
Notes On file: Physician note James Baldwin (not in ofc), Path, labs, Imaging. Does it meet the Minimum Data Set?
Not At All. Call ordering physcian to get the physician note