Siebel eHealthcare Guide > Referrals and Authorization > End-User Procedures >

Managing Referrals or Authorizations

End users use the Referrals/Authorization view to record the necessary information for processing a referral or authorization. Using the Referrals/Authorization form and More Info view tab, users can verify they have recorded all the required information, check on member eligibility, and track the status of referrals and authorizations.

To create a referral or authorization

  1. Navigate to the Referrals/Authorization screen.
  2. In the More Info form, add a record and complete the necessary fields.

    3. Some fields are described in the following table.

    .

    Field
    Comments
    Referral/Authorization #
    Automatically generated by the application.
    Type
    Determines whether the record is a referral or authorization.
    Last Name
    Last name of the member. The application automatically populates the First Name field.
    For more information on adding members, see Adding Eligible Members.
    Status
    Status of this referral or authorization. Valid options include:
    • Open
    • Pending
    • Closed
    • Cancelled
    • Exception Handling
    Requestor Last Name
    Last name of provider. The application automatically populates the Requestor First Name field.
    For more information on adding providers, see Adding Providers.
    Diagnosis Codes
    Diagnosis code for this referral or authorization.
    For more information on adding codes, see the discussion on modifying the List of Values (LOV) in Applications Administration Guide.
    Maximum Visit #
    Maximum number of visits for this referral or authorization.
    Procedure Codes
    Procedure code for this referral or authorization.
    For more information on adding codes, see the discussion on modifying the List of Values (LOV) in Applications Administration Guide.
    Benefits Amount
    The maximum dollar amount for the specified benefit.

End users can use the Actions view tab to record activities related to a referral or authorization. For more information on creating activity plan templates, see To create an activity plan template.

To record referral or authorization actions

  1. Navigate to the Referrals/Authorization screen.
  2. Click the Actions view tab.
  3. In the Actions list, add a new record and complete the necessary fields.
  4. To add a new activity, add a new record in the Activities list and complete the necessary fields.

End users can use the Decision History view tab to associate a referral or authorization with a provider, department, clinic, drug, lab, test or medical supplies.

To record referral or authorization decisions

  1. Navigate to the Referrals/Authorization screen.
  2. Click the Decision History view tab.
  3. In the Approved Actions form, add a record and complete the necessary fields.

    4. Some fields are described in the following table.

    .

    Field
    Comments
    Type
    The type of referral or authorization decision. Valid options include:
    • Lab - Lab referral or authorization.
    • Test - Medical test referral or authorization.
    • DME - Authorization for durable medical equipment, for example, wheelchair.
    • Rx - Specified drug treatment.
    Description
    Description of this referral or authorization.
    Equipment #
    Equipment identification number.
    Rx Drug
    The specific drug treatment requested by the provider. If the provider requests a unauthorized drug, then they must indicate the quantity, dosage, and expected treatment before submitting the request.
    Rx Dosage
    The specific dosage of the requested drug treatment. If the provider requests a unauthorized drug, then they must indicate the quantity, dosage, and expected treatment before submitting the request.

  4. In the Approved Providers and Facilities list, add a record and complete the necessary fields.

    5. Some fields are described in the following table.

    Field
    Comments
    Provider Last Name
    Last name of the provider. The application automatically populates the Provider First Name and ID#.
    For more information on adding providers, see Adding Providers.
    First Name
    First name of the member. For more information on adding members, see Enrolling Members in Health Programs.
    Facility
    The facility where the treatment will be performed. The application automatically populates the remaining fields.
    For more information on adding facilities, see Adding Facilities.

To add attachments related to referrals and authorizations

  1. Navigate to the Referrals/Authorization screen.
  2. Click the Attachments view tab.
  3. In the Attachments list, add a record.
  4. In the Attachment Name field, click the select button.
  5. In the Add Attachment dialog box, do one of the following:
  6. Click Add.

    7. The remaining fields are automatically updated using the selected file's properties.


 Siebel eHealthcare Guide 
 Published: 04 June 2003