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. Inbound referrals for non-PPO plans land in Epic workqueues and each has to be matched to the visit: when a valid referral exists it is assigned, and when none is found a new request has to be created in the payer's review application, with an approved result then built into a new Epic referral shell. Doing this by hand across payers is slow, and an unhandled referral leaves the visit exposed to denial.

Automation Solution

This automation processes internal referrals for non-PPO plans by assigning a valid referral to the visit, or creating a new review request when none exists and building the approved referral shell in Epic.