managed care speciality referrals & authorization policy and

UNIVERSITY of NORTH TEXAS HEALTH SCIENCE CENTER at Fort Worth

Education, Research, Patient Care and Service

MANAGED CARE SPECIALITY REFERRALS & AUTHORIZATION

POLICY AND PROCEDURES

MSRDP Operating Procedure Number: MSRDP-2.006

Effective Date: December 1, 2000

Prepared By: MSRDP Business Administration And UNTHSC Quality Management

Purpose: To ensure referral and pre-authorization/documentation of each patient referral

Approval: ________________________________________________________________________

1.0 Policy. To ensure the effective management of referrals to specialists for all patients

enrolled in a Managed Care Plan. To ensure required documentation and pre-authorization

are obtained, for the referral or procedure, as required by the managed care payer prior to a

visit being scheduled or procedure performed. All specialty referrals require Primary Care

Physician (PCP) authorization. Documentation of all referrals and authorizations must be

placed in the patients’ medical record and entered into the Siemens Signature System

Referral Tracking Module.

2.0 Purpose. To ensure referral and pre-authorization/documentation of each patient referral

3.0

Definitions.

Managed Health Care Plan/Third Party Payer. An organization financially

responsible for the health care utilized by its subscriber/members. This may be a health

maintenance organization, (HMO), capitated independent practice association, (IPA),

or a preferred provider organization, (PPO).

4.0

Procedures.

4.1 All referrals from physicians require PCP approval and/or referral form.

4.2 PCP Referral Responsibilities

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MSRDP Policy & Procedure

Managed Care Specialty Referrals & Authorizations

1. Physician determines that referral to a specialist for the performance of a

procedure is necessary.

2. Physician documents the need for referral or procedure in the patient’s

medical record. Documentation of basic diagnostic testing is in the

medical record. PCP documents a clinical summary containing clinical

data and reason for referral. PCP must also document if request is for

evaluation only or evaluation and treatment.

3. All referrals from physicians require PCP approval and/or referral form

4. The referral form should include at a minimum:

a. Patient name and membership number

b. Referring physician name, address and phone number

c. Referred-to physician information (including name, address and

specialty)

d. Reason for referral

e. Physician signature or stamp

f. Medical record is given to the physician’s assigned nurse or medical

assistant.

4.3 Staff Referral Responsibilities:

1. Patient’s managed care plan/third party payer is identified.

Specialty clinics are to ensure that referral had been obtained

and/or authorized by appropriate managed care plan/third party

payer.

2. Record is reviewed to ensure appropriate documentation and

signatures

3. Copy of each Consultation Request is submitted to designated staff

for tracking of UNTHSC and TIOPA referrals.

4. Referral/Pre-certification Form is completed.

5. Referral Authorization forms will be requested from the patient at

check-in. Patients who cannot provide a referral form or number

upon check-in will be required to sign a letter of “no referral

release” prior to obtaining services or the appointment will be

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MSRDP Policy & Procedure

Managed Care Specialty Referrals & Authorizations

rescheduled until the patient can obtain a completed referral form

from the referring physician or referring physician office.

4.4 The referral is then mailed, faxed or completed via telephone. Method of

communication is based on: (1) urgency for referral need or (2) MCO fax

or telephone availability.

4.5 Referral Responsibilities:

1. Referral information is entered into the Siemens Signature Referral

Tracking module.

2. Upon receipt of Authorization/Referral Number, specialists’ office is

notified via fax or telephone.

3. Referral Number will be written on the Consultation Sheet and entered

into the Signature Referral Tracking module.

4. Appointment is scheduled with specialist and patient is notified.

5. Follow-up via mail to the specialist with the inclusion of lab results,

radiology reports or other pertinent clinical data as requested by the PCP.

6. Specialists’ report of patient care should be received via either fax or mail.

According to TIOPA or UNTHSC direct contract criteria.

7. Nursing staff reviews report and pulls chart. If immediate action is

necessary, nursing staff notifies PCP of the receipt of report. If further

review is necessary, report is placed in chart and placed in slot for review

by the physician.

5.0

References.

Siemens Signature System Training Manual

Applicable managed health care plan provider procedure manuals.

6.0 Follow-Up and Review. Policy to be reviewed as needed or every three (3) years.

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MSRDP Policy & Procedure

Managed Care Specialty Referrals & Authorizations

7.0 Responsibility.

Senior Associate Dean and Chief Medical Officer

Vice President, Practice Operations and Chief Administrative Officer

Senior Administrative Official in each Patient Care Department

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