CLAIMS WITH REFERRALS

[winiawski98]

Because I have been billing Primary care  for 20 years and now have a podiatry client, i have no idea how to submit referrals with claims.  If an insurance only gives a paper referral, do i have to send that claim on paper and attach the referral to it?  Someone told me I can state in box 19 that referral on file?  Please advise..

[kristin]

When you say referral, are you talking about a patient with, say, an HMO, that requires a referral/auth number from their PCP? If so, depending on what PM software you use, there are various ways to have that number show up on an electronic claim. Or are you talking about something else?

[winiawski98]

I'm actually referring to both..
 Patients who need a pre-auth or referral number, I know it goes on the claim form.  But what about patients that are given paper referrals that have no auth #, no precert, no referral # and no specified # of visits..  The paper referral is basically something printed out of the primary care doctor's EMR system that usually states the patients demographics, dx and the name address of the podiatrist that they are referring to..  What do I do with that piece of paper? Is is irrelevant?  Someone told me they send the claims on paper and attach the referral.. that doesn't seem right to me though.

Thanks again

Josephine

[kristin]

I see what you are saying now. No, you don't need to send the claim on paper with the referral attached. There are several ways to handle this, depending on what the doctor wants you to do/the reason for the referral. You already know that if an auth # is present, how to get that on the claim, so that takes care of that.

For everyone else with a referral, here are some options:

1. If the patient is being referred for an actual consultation, and not a transfer of care, list the referring doctor in the referring provider section of the claim, and keep the referral in the patients chart. That way the doctor is covered on proof that the first of the three needed "R's" is being met in billing a consultation code.

2. Some offices always list the referring doctor in the referring provider section of the claim, even when it is not necessary to process the claim, others do not. That decision is up to the doctor. Some want to be able to track referrals for various reasons, others do not care. In my office, we do not care, and when I get a paper referral from another providers EMR on my fax machine(we don't do EMR in my office), or the patient hands me one, I just stick it in their chart, and my doctor will dictate in the tx note that the patient was referred by Dr. So and So. Come to think of it, none of the doctors I bill for bother with adding the referring doctor, unless it is needed to process the claim.