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Referral Process

  • The department is in charge of managing information directly with the medical group and each patient.

  • Department is responsible of processing referrals, sending documentation to specialists and scheduling appointments for patients.

We use the referral tracking system integrated into IMS


Analyze the clinical note to ensure we have the main elements such as:

  • Diagnosis with icd 10 code
  • Referral indication
  • Referral note
  • If all three are there it’s our “good to go”, we can start to fill in the request form via the Medical Group portal depending if it’s HMO or PPO
  • Agents select specialist contracted with patients insurance/ medical group & finding offices closer to patients home.
  • If request is promptly authorized, the status automatically will move onward to pending appointment, otherwise it will go to pending authorization status.

Time Frames

Referral department follows below timeframes to ensure we meet with health plan guidelines

Urgent/ Stat requests
24-72 hrs

5-7 business days

Prior Auth

This status is checked on a daily basis.

Once the Medical Group has authorized the request:

1. The referral is uploaded into EMR & documents
are gathered to be sent via email or fax

2. Documentation is key to continue to our next step.

Pending Appointment

  1. Ensure all supporting documents have been received by the specialist office and schedules first available appointment.
  2. Agents is will give patient details of appointment via phone. Agent will try to contact patient three times, if agent does not successfully do so; agent will then send a letter with details via mail or email.
  3. Documentation is key throughout our referral process
  4. Change status to:
    • Done
    • Done Report Pending
    • Patient Refused

Special Notes

  1. Finally, agent will complete referral by obtain specialist notes and ensuring they are forward to providers for review.
  2. Status will then change to “Done report received”
  3. Part of the referral process is to ensuring all specialist notes are requested and received so this tracking is checked on a daily basis.