User Guide — Authorizations and Referrals

athenaCollector

Authorizations and referrals are attached to specific patient insurance policies; multiple authorizations and referrals can be added to a specific policy. Authorizations and referrals are identified using an authorization or referral number. athenaOne handles authorizations and referrals in the same way. (The authorization or referral number appears in CMS-1500 block 23.)

Note: athenahealth offers an integrated authorization management service (athenaOne® Authorization Management). If you subscribe to athenaOne® Authorization Management, athenahealth completes authorization work for you, including obtaining precertification to perform future services and logging referrals with payers. athenaOne® Authorization Management is an optional add-on service for athenaCollector and athenaClinicals. For more information, see Authorization Tracker.

 

Primary care physicians frequently send patients to specialists. Insurance companies often require that patients obtain a referral to see a specialist, so physicians must track the following:

  • Incoming referrals from primary care physicians
  • Outgoing referrals to specialists

In addition, some insurance companies require that patients obtain prior authorization from the insurance company for certain procedures. These requirements vary with the insurance package. Authorizations and referrals must be included on the claim in order for it to be paid.

 

 

 

You can use athenaOne to add, track, update, and complete incoming and outgoing authorizations and referrals. You can access athenaOne authorization and referral tools throughout the workflow (Schedule Appointment, Quickview, Check-in, Eligibility and Phone, and Claim Edit).

 

If an authorization/referral number exists, a message appears on the patient's Quickview page under the Authorization heading in the Insurances section and on the Check-in page (for example, "4 visits approved | 2 visits left"). The authorization/referral number also appears in a menu on the Schedule Appointment and Claim Edit pages.

 

Selecting an existing authorization or referral from the Authorization menu in the appointment workflow pages does the following:

  • Adds the authorization/referral information to the claim
  • Decrements the number of "visits left" under the authorization/referral

When you add a new authorization or referral number, the fields that appear to the right of the Authorization label are used for printing, description, and tracking purposes only. Errors in these fields do not affect the claim in any other way (for example, a claim will not be put into HOLD).

 

You can track all incoming and outgoing referrals on the Authorization Worklist page: On the Main Menu, click Patients. Under Care Coordination, click Authorization Worklist.

 

 

 

Some large, multispecialty practices have providers who need to send patient referrals to other specialists within the organization. When referrals are sent to outside providers, they are sent by AthenaFax or by paper printout. However, when referrals are sent to providers within the same athenaOne tablespace (practice ID), two different workflows can be used.

 

 

Your organization has multiple specialties, including a Pediatric primary care department and an Endocrinology department. A pediatrician needs to send her pediatric patient to Endocrinology for a consult.

 

 

If you send a referral order to a fax number that is considered internal to the organization, the referral cannot be processed by the athenahealth document services team. Instead, the document is faxed internally and processed by the practice.

  1. Create the referral order from an encounter or from an order group.
  2. Select the clinical provider within your organization to whom you are referring the patient.
  3. Save and sign the order.
  4. Depending on the task assignment overrides set up for your organization, the provider or staff member selects the action SUBMIT by Athena Fax.
    The referral order appears in the Clinical Inbox as an Unknown document in Unprocessed status — most likely in the Dept. STAFF bucket (depending on the TAOs set up for Unknown documents).
  5. The staff member must manually process this document and classify it as an Admin - Referral document.

 

 

Set up referral practice roles

 

If your practice has one central repository for all referrals, create a practice role for referrals.

  1. Display the Practice Roles page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Other, click Practice Roles.
  2. Name — Enter a practice role name for referrals.
  3. Users — Select the users who will receive referral tasks.
  4. Departments — Select the departments that will receive referral tasks.
  5. Click Save.

If your practice prefers to route referrals to individual departments, create referral practice roles for each department.

  1. Display the Practice Roles page: On the Main Menu, click Settings > Clinicals. In the left menu, under Practice Links — Other, click Practice Roles.
  2. Name — Enter a practice role name for a specific department, for example, "endoreferrals."
  3. Users — Select the users who will receive referral tasks for the department.
  4. Departments — Select the departments that will receive referral tasks.
  5. Click Save.

Send intrerdepartmental referrals

  1. Create the referral order from an encounter or from an order group.
  2. Select the clinical provider within your organization to whom you are referring the patient.
  3. Save and sign the order.
  4. Staff members assigned to the referrals practice role receive the order as a task.
  5. To process the referral task, staff members do the following:
    1. Click the more actions link at the bottom of the task.
    2. Select the action Leave in SUBMIT to and select the appropriate department referral role.
    3. Click Save.
  6. The staff member who monitors the department-specific referrals row (called "endoreferrals," for example) receives a task with the referral order in SUBMIT status.
  7. After the referral is acted on, the staff member selects this action: Order Submitted by paper Print-out.

 

 

 

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