Referrals: Authorizations & Denials
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Referrals Resource Pages
Referrals: Authorizations & Denials | Referrals: Incoming & Internal | Referrals: Outgoing
Epic’s Referrals functionality allows users to create and edit referral records, document authorization details, associate visits with referrals, track changes and communications regarding the referral, identify authorization needed, and review and triage for clinical appropriateness regarding scheduling.
Resources
Beacon (Recurring Medication Plan) Referrals
Beacon (Recurring Medication Plan) Referrals
- Documenting Pre-Authorization for Recurring Medication Plans - (Handout) The referral record is used to document the pre-authorization numbers that are obtained for treatment plan therapy. Departments will obtain and add the pre-authorization numbers to the referral record.
- Insurance Referral Status for Recurring Medication Plans - (Handout) Insurance referral information can be viewed from the Appointment Desk and indicates whether the referral has been authorized or not, the dates of authorization, and the workqueue where the referral is currently located. Authorization status can also be found from the Treatment Plan Springboard.
- Workqueue List Basics for Recurring Medication Plan Referrals - (Handout) The Workqueue List is used to locate patients with referral or scheduling needs. The Workqueue List can be customized.
Documenting Authorization
Documenting Authorization
- Documenting Referral Authorization - (Handout) When authorization is required for an existing referral attached to an appointment, or the authorization dates documented do not cover the date of the appointment, the referral will fall to the Referral workqueue.
- Documenting Referral Authorization for Commercial Insurance - (Handout) When authorization is required for a patient with commercial insurance for an encounter, a referral must be authorized and linked to the encounter in Epic.
- Documenting Radiology Preauthorization - (Handout) The referral form is used to document the preauthorization numbers that are obtained for radiology imaging appointments.
Department Denial Workqueues (Pre-Cert, Prior Auth, Referral Denials)
Department Denial Workqueues (Pre-Cert, Prior Auth, Referral Denials)
- Department PB Denials - (Handout) How to work a department PB denial workqueue.
- Department HB Denials - (Handout) How to work a department HB denial workqueue.
- Department PB Denials PPT - (Training Resource) The power point presentation for the Department PB Denials lesson.
- Department HB Denials PPT - (Training Resource) The power point presentation for the Department HB Denials lesson.
Department Specific Workflows
Department Specific Workflows
- BMT Referral Workflow - (Handout) When a new patient is referred to UIHC, the Referral Coordinator creates an Abstract Episode, collects information, then initiates the referral process.
Surgical and Procedural Pre-authorizations and Re-authorizations
Surgical and Procedural Pre-authorizations and Re-authorizations
- Cadence Scheduler: Scheduling Procedural Appointments from the Schedule Referrals Workqueue - (Handout) A referral record is automatically created from a case or procedure order. Procedure orders that require appointment scheduling will appear on the Schedule Referrals workqueue.
- LOC Nurses: Using the UIHC PFS Requested LOC Review Workqueue - (Handout) When a patient class requires review by Level of Care nurses, pre-authorization staff will flag the patient’s Auth/Cert for review by LOC. This flag will send the Auth/Cert to the Patient workqueue UIHC PFS Requested LOC Review Workqueue [683582]. After review, LOC staff will update the flag to reflect the result of their review.
- OR Scheduler: OR Scheduler Workflow for Surgical Pre-Authorization - (Handout) OR scheduler documentation will assist pre-authorization staff in obtaining surgical pre-authorization. A Referral Scheduling Status column in the Case Depot will keep OR schedulers informed of the pre-authorization status.
- Pre-Auth Staff: Documenting Surgical/Procedural Pre-Authorizations - (Handout) A referral record is automatically created from a case or procedure order. Once the “schedule by” date (indicating the expected date of service) and CPT codes are entered by the scheduler, if pre-authorization is required, the referral falls to the pre-authorization workqueue to be documented. Once pre-authorization is obtained, scheduling can occur.
Re-Authorization
Re-Authorization
- Coder: Documenting CPT Codes for Surgical and Procedural Cases that Need Re-authorization - (Handout) Case orders that are pre-authorized but need re-authorized will fall to the department’s “Reauth CPT Codes Need Verified” Referral workqueue when the CPT code needs to be documented by a coder.
- Re-Auth Staff: Re-authorizing Referrals for Surgical and Procedural Cases - (Handout) Case orders that are pre-authorized but need re-authorized will fall to the department’s “Needs Reauth” Referral workqueue once the CPT code(s) is documented. This occurs when the procedure performed during surgery differs from the procedure that was pre-authorized, and re-authorization of the referral is needed for the new CPT Code(s).
Related Pages
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