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Scenario for Creating and Authorizing a Referral

The following business scenario features sample tasks performed by a call center representative for health plan company. Your company might follow a different workflow according to its business requirements.

A healthcare provider calls a health plan's call center in order to refer a patient to an orthopedic surgeon. A call center representative receives the call from the provider. The call center representative first authenticates the provider and then looks up the member on the Members screen. By looking at the Member Summary view, she verifies the member's basic eligibility and coverages. She then navigates to the Referrals/Authorizations screen. She creates a new referral and completes the necessary fields. Once she finishes entering the necessary data, she changes the value in the Status field to Open and sets the Sub-status field to Submitted.