288: Referral absent
Denial Occurrence:
- This denial occurs when the referral is missing.
- Referral number can be found on Box# 23 on the CMS1500 form or Locator# 63 on the the UB04 form.
- A referral is provided by a PCP (Primary care physician) / Referring provider to the patient when he/she refers the patient to the specialist.
- For example, when a patient visits a doctor for a routine check-up and a doctor finds symptoms of skin diseases and advises the patient to visit a skin specialist. In that case doctor is considered a PCP / Referring provider and he/she provides a referral to the patient to visit a skin specialist.
- In the HMO or POS plan, it is necessary to visit the PCP. So, a referral is required.
- In the PPO or EPO plan, it is not necessary to visit the PCP. So, a referral is not required.
On Call Scenario:
Claim denied as referral is absent or missing
↓
May I get the denial date?
↓
What plan does patient has? (HMO, PPO, EPO, POS)
↙ ↙ ↘ ↘
↙ ↙ ↘ ↘
HMO POS PPO EPO
↘ ↙ ↘ ↙
↘ ↙ ↘ ↙
Check in system if Could you please send claim
referral# is available back for reprocessing since
↙ ↘ patient plan does not require
Yes No referral#?
↙ ↓ ↓
I have the referral#, can Do you have referral# on file? What is the turn around
you please reprocess OR Is there any hospital claim time?
the claim using it? billed on same DOS where ↓
↓ referral# present? May I have the claim#
Claim denied as referral is absent or missing
↓
May I get the denial date?
↓
What plan does patient has? (HMO, PPO, EPO, POS)
↙ ↙ ↘ ↘
↙ ↙ ↘ ↘
HMO POS PPO EPO
↘ ↙ ↘ ↙
↘ ↙ ↘ ↙
Check in system if Could you please send claim
referral# is available back for reprocessing since
↙ ↘ patient plan does not require
Yes No referral#?
↙ ↓ ↓
I have the referral#, can Do you have referral# on file? What is the turn around
you please reprocess OR Is there any hospital claim time?
the claim using it? billed on same DOS where ↓
↓ referral# present? May I have the claim#
What is the turn around (The above highlighted question & call ref#?
time? is only applicable for
↓ non-hospital billing claims)
May I have the claim# ↙ ↘
& call ref#? Yes No
↓ ↓
Could you please use What is the Fax# or
same referral# & send mailing address to
claim back for send an appeal?
reprocessing? ↓
same referral# & send mailing address to
claim back for send an appeal?
reprocessing? ↓
↓ How much is the time
What is the turn around limit?
time? ↓
↓ May I have the claim#
May I have the claim# & call ref#?
& call ref#?
Important Notes & Actions:
- Please take action as per your process update. Below actions can be different from your process update.
- If the patient plan is HMO or POS and referral is available in the system and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
- If the patient plan is HMO or POS and the referral is not available in the system but the rep finds the referral on his/her system or on the hospital claim and agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
- If the patient plan is HMO or POS and the referral is not available in the system and the rep does not find the referral on his/her system or on the hospital claim then you can either send an appeal or write off the claim. Please work as per your client's instructions.
- If the patient plan is PPO or EPO and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
- Click here to go to Quiz
useful
ReplyDeletevery useful!
DeleteThis is very informative.
ReplyDeleteThank you!
DeleteVery informative and easy to understand.
ReplyDeleteThank you!
DeleteDo we need to get pcp information from rep when referral is not provied or we need to call to pcp to get the referral?
ReplyDeletePCP information is already available in the claim form and please check in the system or the document available for the patient. You may find referral there and if it is not available then do not directly make a call to PCP. Follow the instructions of your client.
Deleteit's helpful to complete claims
ReplyDeleteThank you.
DeleteWhere we can find referral number in CMS-1500
ReplyDeleteWhere we can find referral number in cms-1500
ReplyDelete17a
DeleteBox no 23
ReplyDeleteThanks for your response.
DeleteIf we have referral in hour system but number of visits have expired and Dos is falling between the date range,what will ask to rep?
ReplyDeleteIf the denial is the number of visits expired then you can follow the below scenario,
Deletehttps://www.arlearningonline.com/2022/06/151-payment-adjusted-because-payer.html
If the denial is for referral absent and you have the referral in the file but the number of visits covered under the referral is expired then validate it. Ask for the number of visits covered under the referral and if that is already covered or not excluding this claim. If it is not covered then you can ask to reprocess the claim and if it is covered then you can consider it as no referral on file and ask for appeal details.
Could you please clarify the confusion around the denial patient plan do require a referral there is no referral on file we received a denial do we need to bill patient as patient didn't take approval from his pcp or its providers responsibility to obtain referrals for certain patients with hmo plans before rendering services so do we need to appeal the claim?
ReplyDeleteThe HMO plan does require a referral number. So, when a patient visits a specialist after PCP, then it's providers responsibility to confirm all the details during the Eligibility and Benefit Verification step.
DeleteYou can still ask a patient if he/she has the referral number and use the same referral number. But, if it is not available to patient then you can try to get payment by sending an appeal.