Problem Statement

Referrals must be received, validated, and acted on before a specialist visit, because many payers require an authorized referral on file or the visit denies. When a payer requires a referral and none is on file for an upcoming specialty visit, a request has to go to the PCP before the appointment, or the visit denies. Identifying these patients means manually reviewing reports, and because that review is labor-intensive, it often isn't run regularly, so referrals slip and visits arrive unauthorized.

Automation Solution

This automation identifies specialty-care patients without a referral on file via Epic reports and sends referral requests to the PCP ahead of the specialty visit.