Referral & Prospective Review Policies & Guidelines

Several projects were completed in this focus area, aimed at educating providers as to when referrals and prospective reviews are necessary, and relaxing some rules around the referral/prospective review process.

» Frequently Asked Questions about Referrals and Prospective Review

Frequently Asked Questions
(.pdf | 31k | Version 10.08.07)

» One-Stop-Shop for Health Plans Processing Requirements & Contact Information
Use these links to customize your own reports of referral and prospective review processing requirements by health plan as well as to get health plan contact information and product name information:

Considerations for Using Processing Tables
(.pdf | 44K | Version 10.08.07)

Health Plan Product Names & Abbreviations
(.pdf | 10K | Version 10.08.07)

» Using Standard Referral Actions & CHITA Form

Guideline for Standard Referral Actions
(.pdf | 45k | Version 10.08.07)

CHITA Standard Referral Form
(.pdf | 62k | 04/03)

» Guideline for Women’s Healthcare

Guideline for Women's Healthcare
(.pdf | 33K | Version 10.08.07)

» Numeric Billing Codes on Referrals and Authorizations

Coding Policy
(.pdf | 12K | Rev 6.0 | 4.18.04)

» Tolerance Period for Referral Effective Dates

Tolerance Period Policy
(.pdf | 13K | Rev 6.0 | 4.19.04)

» Reduce Administrative Burden on PCP & Emergency Room

Hospital ER Referral Policy
(.pdf | 11K | Rev 6.0 | 4.19.04)

» Guidelines for Requesting a Prospective Clinical-Medical Review

Requesting Prospective Review Guideline
(.pdf | 23k | Version 10.08.07)

Standard Form
(.pdf | 29k | Version 10.08.07)