Referral Process
What the timeframe within which a STAT and urgent referral must be processed?
STAT referrals - 24 hours
Urgent referrals - 48 hours
What is essential to ensuring a DME order can be closed?
confirm DME was received by patient
A patient with careplus can self refer to dermatologist for the first visit due to this
capitation
This type of complaint can be filed when a member is dissatisfied with the process or timeliness of a referral.
grievance
Referral coordinators should always ensure that outside specialists send these back after the specialist visit?
consult notes
How long is an authorization/order usually active ‘good’ for?
90 days
Where (location in ECW) does the fax drive person assign incoming outside referral requests?
the D jelly bean to the assigned referral coordinator
DME orders for MA plans need to be processed through what?
the preferred DME supplier for health plan? (ex rotech, integrated)
Where can you find if a provider or service is capitated?
preferred provider directory/capitation list (par/nonpar/cap vendor in green)
The maximum time health plan has for processing a standard (non-urgent) referral per CMS guidelines?
14 calendar days
A routine imaging order comes in from a specialist to be completed at hospital, what should referral coordinator do first?
discuss with PCP to see if can be deferred to preferred imaging facility
(it is essential that patient is notified of this and confirms and also the specialist who ordered must be CC’d on results)
True/False: Hospice services require an authorization and are always STAT
FALSE
While hospice is always STAT, hospice does NOT require authorization just a referral faxed with the clinical documentation.
If there is a question regarding an imaging order from L JELLY BEAN what should employee do?
speak with PCP directly
A patient is requesting a new power scooter per MD due to battery not working and she got the scooter 4 years ago, who needs to be contacted regarding this?
the original DME supplier from who they obtained scooter from through insurance
Provider creates a referral for an out of network ENT what should the referral coordinator do?
notify doctor to see if order can be redirected to preferred ENT provider
This type of Medicare plan usually allows patients to see specialists without referrals.
PPO (Preferred Provider Organization)
If a referral coordinator is noticing specific issues with a certain specialist (trends) what should they do?
save examples and notify manager so they can make PR aware
A new patient visit 99204 request comes in from a specialist what do you look for first?
CHECK TO SEE IF OUR PCP REFERRED OUT FOR THIS
What is time frame for processing routine referrals?
72 hours
CMS requires MA plans to ensure referrals for DME meet this standard before approving.
medical necessity
Referral coordinators should ensure referrals for behavioral carve outs are sent to this.
the delegated behavioral health vendor (e.g., Optum / Carelon?)
A patient is seeing pinnacle for home health and doctor sends out a referral for concierge home health care per patient request, what will insurance most likely do?
They will deny the request. Patient would need to 'term services' with pinnacle to be able to start with a new home care agency.
What is one of the first things a referral coordinator should do when they get a auth request from specialist to ensure they are not duplicating work?
check to see if duplicate request
Two items that must be on an authorization request to show why and what the request is for?
CPT and ICD-10 codes
Referral coordinator receives confirmation of appointment for an open referral from the PCP, what happens to the referral?
the referral goes into pending once appointment date entered
If you have a question regarding where to process a DME item through for a specific health plan where do you go?
look on preferred provider/capitation list or health plan portal
Members traveling in-state, such as from Tampa to Jacksonville, must still follow this rule
staying in-network for HMO referrals
This Medicare program type requires close management of referrals to reduce unnecessary costs and hospitalizations.
Medicare Advantage or ACO reach (depending on context)
***DAILY DOUBLE***
You are made aware that a new patient visit request has come in from an outside specialist that we did not refer to, what is the best course of action?
ensure this is discussed with PCP so that we can bring in patient to evaluate first before sending out
(unless emergent or special circumstances)
What should referral coordinator document for provider to review on incoming authorization request from a specialist?
What exactly the request is for (CPT codes) and why with the diagnosis codes (ICD-10 codes)