13Referrals and Authorization
Referrals and Authorization
This chapter describes referrals and authorization. It includes the following topics:
About Referrals and Authorization
Siebel Healthcare allows you to track referrals to other providers and authorizations of specific healthcare services. Service agents use the Referrals\Authorizations screen to collect the information required for referral and authorization approval, validate the fields, initiate workflow, and track the status on behalf of a provider, member, or other inquiring party. This information can then be integrated with back-office systems using a prebuilt referral and authorization ASI. For more information, see Siebel Integration Messages.
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.
Administrator Procedures for Referrals and Authorizations
The following administrator procedures are described in this section:
Creating an activity plan template
Activity Plan Templates allow you to create and manage activities related to referrals and authorizations. You define templates using the Administration - Data screen’s Activity Templates and Activity Template Details views.
To create an activity plan template
Navigate to Site Map, Administration - Data, and then the Activity Templates.
In the Activity Templates list, add a record.
In the Name field, type a name for the template.
In the Type field, choose FINS Referrals Authorizations.
Complete the remaining necessary fields.
For more information on creating activity templates, see Siebel Applications Administration Guide.
Creating Activities for the Template
Use the following procedure to create activities for the template.
To create activities for the template
Navigate to Site Map, Administration - Data, and then the Activity Templates.
In the Activity Plan Templates list, select a template.
Click the Activity Template Details view tab.
In the Activity Template Details list, add a record.
Complete the necessary fields for each activity assigned to the template.
End-User Procedures for Referrals and 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.
The following end-user procedures are described in this section:
Creating Referrals or Authorizations
End users can create referrals or authorizations from the Referrals/Authorization screen.
To create a referral or authorization
Navigate to the Referrals/Authorization screen.
Add a record and select the request type: Authorization or Referral.
Drill down on the Tracking #.
Click the More Info view tab and complete the necessary fields described in the following table.
Field Comments 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 to Group Policies.
Status
Status of this referral or authorization.
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 Siebel Applications Administration Guide.
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 Siebel Applications Administration Guide.
# of Visits Requested
For referral requests, the number of doctor visits requested for approval.
Maximum Benefit
The maximum dollar amount for the specified benefit.
Associating Actions and Providers to Referral or Authorization Requests
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 Administrator Procedures for Referrals and Authorizations.
To associate an action or provider with a referral or authorization
Navigate to the Referrals/Authorization screen.
In the Referrals/Authorizations list, drill down on the tracking # of the desired request.
Click the Actions view tab.
In the Actions list, add a new record and select the desired activity template.
Save the record.
The activities associated with the activity template selected are automatically entered in the Activities list.
To add additional activities, add a new record in the Activities list and complete the necessary fields.
Recording Approval Decisions for Referrals or Authorizations
End users can use the Decision History view tab to record for each referral or authorization, the approved actions and physician and facility referrals. Actions include things such as a medical equipment and prescription drug supplies.
To record referral or authorization decisions
Navigate to the Referrals/Authorization screen.
In the Referrals/Authorizations list, drill down on the tracking # of the desired request.
Click the Decision History view tab.
In the Approved Actions form, add a record and complete the fields 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.
In the Approved Providers and Facilities list, add a record and complete the fields 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.
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.