Referral & Prospective Review

Several projects were completed in this focus area, aimed at educating providers as to when referrals and prospective reviews are necessary, and relaxing some rules around the referral/prospective review process.

Frequently Asked Questions about Referrals and Prospective Review

» Frequently Asked Questions
   (.pdf | 31k | Version 10.08.07)

#1 - One-Stop-Shop for Health Plans Processing Requirements & Contact Information
Use these links to customize your own reports of referral and prospective review processing requirements by health plan as well as to get health plan contact information and product name information:

» Referral Guidelines for Managed Care Products
   (user defined report — now provided by OneHealthPort)

» Prospective Review Guidelines for All Products
   (user defined report — now provided by OneHealthPort)

» Inpatient Stay Review for Fee-for-Service Products
   (user defined report — now provided by OneHealthPort)

» Considerations for Using Processing Tables
   (.pdf | 44K | Version 10.08.07)

» Health Plan Product Names & Abbreviations
   (.pdf | 10K | Version 10.08.07)

#2 - Using Standard Referral Actions and CHITA Form

» Guideline for Standard Referral Actions
   (.pdf | 45k | Version 10.08.07)

» CHITA Standard Referral Form
   (.pdf | 62k | 04/03)

#3 - Guideline for Women’s Healthcare

» Guideline for Women's Healthcare
   (.pdf | 33K | Version 10.08.07)

#4 - Numeric Billing Codes on Referrals and Authorizations

» Coding Policy (.pdf | 12K | Rev 6.0 | 4.18.04)

#5 - Tolerance Period for Referral Effective Dates

» Tolerance Period Policy (.pdf | 13K | Rev 6.0 | 4.19.04)

#6 - Reduce Administrative Burden on PCP & Emergency Room

» Hospital ER Referral Policy (.pdf | 11K | Rev 6.0 | 4.19.04)

#7 - Guidelines for Requesting a Prospective Clinical-Medical Review

» Requesting Prospective Review Guideline
   (.pdf | 23k | Version 10.08.07)

» Standard Form
   (.pdf | 29k | Version 10.08.07)

Referral & Prospective Review Quick Link:

1. One-Stop-Shop for Health Plans Processing Requirements & Contact Information
2. Using Standard Referral Actions and CHITA Form
3. Guideline for Women’s Healthcare
4. Numeric Billing Codes on Referrals and Authorizations
5. Tolerance Period for Referral Effective Dates
6. Reduce Administrative Burden on PCP & Emergency Room
7. Guidelines for Requesting a Prospective Clinical-Medical Review

Frequently Asked Questions about Referrals and Prospective Review