A "good" referral is one that truly helps coordinate care among cooperating providers, while minimizing the hassles of dealing with any payer/insurance issues regarding eligibility and authorization. Accurate and complete information about the patient and the care being ordered help ensure these goals can be achieved.
Why the "Reason for Referral" is so important.
The first place that a specialist will look for clinical information on the referral is in the Reason for Referral section. Combined with the order type and ICD9-coded diagnosis, these should summarize specifically what the referring provider expects from the specialist. This information also provides important information for Clarity to use in processing the insurance, for example, determining whether pre-authorizations are required and providing the essential information required to obtain those authorizations.Choosing the order typeIt is very important that the order type communicates your intentions to the specialist.- Imaging Study: You must select "Imaging Study" for diagnostic imaging order such as such as CT scans, MRIs, PET scans, x-rays, ultrasounds and bone scans. In the "Reason for Referral" field, specify the type of study and the body part. If you know the CPT code, please include it.
- Consult: Used when the patient is referred to a specialist for examination and consultation with the referring provider. The referring provider usually receives a report documenting the opinion based on the findings of that examination. If the specialist is on Clarity, they can return these reports online to you.
- Evaluate and Treat: Used when the patient is referred for an evaluation and continued visits for treatment.
- Evaluate and Treat, Surgery/Procedure if Indicated: Used when the patient is referred for an evaluation and continued visits for treatment also requesting that the specialist order or perform any surgery or procedures required in treatment. The specialist is responsible for obtaining authorizations for the surgeries or procedures for these patients once they have created a patient care plan.
- Itemized Services: Used when the patient is referred for DME or other specific services.
- Referral Extension: Used when the patient is referred for additional visits to a provider who is currently providing care based on a care plan agreed upon by the referring provider and the specialist.
- Routine Care: Used when the patient is referred for routine care that is not provided by the referring office, for example, OB/GYN.
- Assume Management: Used when the patient is referred for care and the referring provider is handing of the management of the condition to the referred to provider. Should the referred to provider determine that a additional diagnostic tests, therapies, or a consultation with yet another clinician are needed, the original referring provider would not be required to seek authorization. Regular reporting back to the referring provider is still expected.
Dealing with insurance
Among the most common issues that slow the processing of referrals are inaccurate or incomplete insurance information for the patient, and insufficient detail in the clinical requirements for the order.Accurate insurance information for patientsWhen Clarity processes a referral, we confirm the patient's eligibility for the plan or plans you specify. Some insurance companies are very particular about this data, and will not, for example, provide a member number even though we have complete and accurate identifying information including name, address, DOB and even SSN. So please, include as much accurate demographic and insurance information as you have in each referral.Why is the provider's name on an authorization different than the referring provider I listed?Some plans require that a "provider of record" be established. For the plan's purposes, all referrals come from this provider even if a different provider (in the same contracted practice) actually saw the patient. Typically, the patient is the only person who can change this designation of the PCP of record.Be as specific as possible in your referralSome plans (notably Regence Selections and NPN) require a specific provider for "Evaluate and Treat" orders, and will reject orders that attempt to "refer to practice" (any contracted provider in that practice). When in doubt, it is best to be as specific as possible. Contact the Clarity Service Center if you need assistance.
|
We want your feedback:
Send us a note
or give us a call at 877.392.8802 or 206.602.1900
Privacy and Security Policy|Terms of Use
