Purpose. Ensure referrals for specialty care, diagnostic services, and medical procedures are processed promptly, supported by complete clinical information, tracked to completion, and documented in the patient record.

Scope. Applies to support staff, clinical staff, and providers involved in internal or external referrals and prior-authorization requests. Health-plan and medical-group requirements vary, so staff must use the current network directory, portal, forms, and instructions for the patient’s plan.

📚 Resources Needed

  • Patient chart and current insurance information.

  • Current health-plan or medical-group network directory.

  • Current referral or authorization form, portal, or approved submission channel.

  • Relevant progress notes, diagnosis, order, test results, medication history, and other supporting clinical information.

  • EHR referral work queue, task system, or other approved tickler system for follow-up.

✅ Before You Start

  • Verify the patient’s identity, active eligibility, assigned primary care provider, health plan, and medical group.

  • Confirm the provider’s order, the requested specialty or service, the clinical reason, and the requested urgency.

  • Check whether the service needs only a referral, requires prior authorization, or may be scheduled directly.

  • Confirm that the requested specialist or facility is in network. Do not promise coverage or payment.

  • For urgent clinical concerns, notify the provider or licensed clinical staff immediately. Emergency care must never be delayed while eligibility or authorization is checked.

🚀 Tips & Tricks

  • Attach complete records the first time. Missing clinical information is a common cause of delay or denial.

  • Use a single tracking location. Every referral should have an owner, current status, next action, and follow-up date.

  • Record confirmation details. Save the submission date, portal or fax confirmation, reference number, and recipient when available.

  • Set the next follow-up before leaving the task. Do not rely on memory or an open inbox.

  • Keep the patient informed. Explain what happens next without promising an approval date or outcome.

📘 Instructions

Step 1 Review The Order And Request

  • Confirm the ordering provider, diagnosis, requested specialist or service, urgency, and clinical question.

  • Clarify incomplete or conflicting instructions with the ordering provider before submitting.

  • Confirm whether the request is internal, external, in-network, or out-of-network.

Step 2 Confirm Referral And Authorization Requirements

  • Use the patient’s current health-plan or medical-group resources to determine whether prior authorization is required.

  • Confirm the correct network, submission method, form, and required supporting documents.

  • If requirements are unclear, contact the plan or medical group before scheduling a service that may require approval.

Step 3 Prepare The Referral Or Authorization Request

  • Complete all required fields, including patient identifiers, plan information, ordering provider, diagnosis, requested service, urgency, and destination provider or facility.

  • Attach the provider order and all relevant medical information needed to support medical necessity.

  • Review the request for accuracy, legibility, completeness, and minimum-necessary use of protected health information.

Step 4 Submit And Document

  • Submit through the approved portal, secure fax, or other authorized channel.

  • Document the submission date, method, destination, confirmation, reference number, and staff owner in the patient chart or approved tracking system.

  • If the request is rejected as incomplete, correct it promptly and document the resubmission.

Step 5 Track The Request

  • Maintain an organized referral work queue or tickler system. At minimum, track the patient name, referral date, referral type, authorization status when applicable, appointment date, whether the appointment was kept or missed, next action, and responsible staff member.

  • Review open items routinely and follow up with the plan, medical group, specialist, facility, provider, or patient as needed.

  • Escalate urgent requests, repeated delays, denials requiring provider action, and requests nearing a health-plan deadline.

Step 6 Notify And Coordinate With The Patient

  • Give the patient the approved specialist or facility information and scheduling instructions once available.

  • Explain any required next steps, expiration date, or plan instructions shown on the authorization.

  • Document patient contact attempts and the information provided. If the patient misses the appointment, attempt outreach and notify the provider when clinically appropriate.

Step 7 Close The Referral Loop

  • Confirm the consultation, procedure, or diagnostic service occurred.

  • Ensure the specialist, procedure, or diagnostic report is received and added to the medical record within 30 days of the appointment or procedure.

  • If the report is not received within 30 days, contact the specialist or service location and request it.

  • Route the report to the ordering provider for review, document the review, and arrange or communicate follow-up care as directed.

  • Close the referral only after the outcome, report, provider review, and required patient follow-up are documented.

👥 Roles & Responsibilities

Role

Primary Responsibility

Ordering Provider

Defines the clinical need and urgency, supplies the order and supporting documentation, responds to clinical questions, and reviews the resulting report.

Clinical Staff

Assists with clinical documentation, urgent escalation, report routing, and follow-up instructions within scope.

Support Staff

Verifies administrative requirements, submits complete requests, tracks status, communicates approved next steps, and closes assigned tasks only after documentation is complete.

All Staff

Protect PHI, use approved channels, document actions accurately, and escalate unresolved or time-sensitive issues.

🛠 Troubleshooting

The request was denied. Route the denial and reason to the ordering provider. Confirm whether additional records, a corrected request, peer-to-peer review, appeal, or a different in-network service is appropriate. Do not change clinical information without provider direction.

The authorization is approved but the specialist cannot schedule. Confirm the authorization destination, approved service, effective dates, and network status. Contact the plan or medical group for redirection when needed.

No status is available. Verify that the request was received using the confirmation or reference number. Contact the receiving entity through the approved channel and document the follow-up.

The patient cannot be reached. Use approved outreach methods, document each attempt, and notify the provider when the referral is urgent, time-sensitive, or repeatedly unsuccessful.

The specialist report is missing. Request the report from the specialist or procedure site. Continue follow-up until received, then route it to the ordering provider for review.

✅ Completion Check

☐  Eligibility, medical group, and network requirements were verified.

☐  The referral or authorization request was complete and submitted through an approved channel.

☐  Submission confirmation, reference number, status, next action, and owner were documented.

☐  The patient received clear scheduling or next-step information.

☐  The appointment outcome was tracked, including whether the appointment was kept or missed.

☐  The resulting report was received within 30 days or follow-up was initiated.

☐  The ordering provider reviewed the report and follow-up care was documented.

☐  The referral was closed only after the loop was fully completed.