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CM

Authorize Referral

Authorization Determination

Description

The Authorize Referral business process is responsible for referrals between providers that the State Medicaid Agency (SMA) approves for payment, based on state policy. Examples are referrals by physicians to other providers for laboratory procedures, surgery, drugs, or durable medical equipment. The SMA uses this business process primarily for Primary Care Case Management programs where additional approval controls deemed necessary by the state. Most States do not require this additional layer of control. NOTE: MITA contains three (3) different authorization business processes: 1. Authorize Service - the standard process of prior authorization of services. 2. Authorize Treatment Plan - the approval of a treatment plan prepared by a care management team in a care management setting. 3. Authorize Referral - specifically the approval of a referral to another provider, requested by a primary care physician. The Authorize Referral business process may encompass both a pre-approved and post-approved referral request, especially in the case where the member required immediate services. This business process may include, but is not limited to, referrals for specific types and numbers of visits, procedures, surgeries, tests, drugs, durable medical equipment, therapies, and institutional days of stay. The SMA evaluates requests based on urgency, state priority requirements, and type of service/taxonomy (durable medical equipment, speech, physical therapy, dental, inpatient, out-of-state). It validates key information, and ensures that the referral is appropriate and medically necessary. After review, staff approves, modifies, suspends for additional information or denies the request. This business process sends an alert to Manage Case Information business process. A post-approved referral request is an editing/auditing function that requires review of information after the referral is complete. A review may consist of verifying documentation to ensure that the referral is appropriate, and medically and/or functionally necessary, and validating provider type and specialty information to ensure alignment with agency policies and procedures. Post-approved validation typically occurs in the Process Claim or Process Encounter business processes.

Business Process Template

Trigger events
Environment-based
  • Provider submits a request to refer patient to other service providers in accordance with state policy.
  • Provider submits additional information for existing referral request.
Interaction-based
  • Receive referral request from Health Information Exchange (HIE) via Accredited Standards Committee (ASC) X12 278 Health Care Services Review Request and Response transaction.
  • Receive referral request from requestor via ASC X12 278 Health Care Services Review Request and Response transaction.
Results
  • Send the authorize referral response to the referring provider and the consulting provider.
  • Alert to send referral information to requestor via ASC X12 278 Health Care Services Review Request and Response transaction.
  • If applicable, alert sent to submitter via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA).
  • Alert sent to Manage Applicant and Member Communication to send notification of authorized referral response.
  • Alert sent to Manage Case Information business process for purposes of responding to member inquiries about the status of a referral request or a filing of a grievance or an appeal about the referral response.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive referral request from authorized provider.
  • 2. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and requestor has completed all required fields.
  • 3. Validate that the provided information is authentic. a. If applicable, alert sent to submitter via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment, and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA). END: Business process stops.
  • 4. Assign a tracking number.
  • 5. Prioritize Referral Authorization Request.
  • 6. Validate the following:
  • 7. Member eligibility- for social service model, this entails assessing member’s health, functional, and socio-economic status
  • 8. Eligibility for requesting and referral providers
  • 9. Service coverage and referral requirements
  • 10. Diagnosis code
  • 11. Procedure code/or procedure groupings
  • 12. Check for medical or functional necessity and appropriateness.
  • 13. Check against current referral authorizations for duplicates.
  • 14. Validate completeness of supporting documentation.
  • 15. Deny based on insufficient/erroneous information for referral. Go to step 13.
  • 16. Suspend the referral request based on need for additional information - send request for additional information. Go to step 13.
  • 17. Approve referral request (this includes approved with modifications).
  • 18. Send alert to send referral authorization to requestor via ASC X12 278 Health Care Services Review Request and Response transaction.
  • 19. END: Send alert to notify member, referring provider, and referred-to provider of authorization determination.
  • Alternate Path: For the authorization of some services, States may use the post-approval rather than the prior authorization business process. The post-approval business process will cover all steps listed above, but they may execute in a different order depending on state rules.
Predecessor processes
Successor processes
Shared data
  • Member data store including demographic information
  • Provider data store including provider network Information
  • Health Information Exchange (HIE) data store including health information, clinical record, and clinical data
  • Claims data store including adjudication information
  • Plan data store including health benefits information
Constraints

The authorize referral request information will conform to the format and content in accordance with state-specific reporting requirements, e.g., using a HIPAA Transaction Standard Companion Guide.

Failures
  • The SMA receives incomplete referral request information.
  • Requestor not authorized to make referral request.
  • Member not eligible for referred provider services.
Performance measures
  • Time to complete the process: e.g., Real Time response = within __ seconds, Batch Response = within __ hours
  • Accuracy with which referral authorizations are approved or denied = ___%
  • Consistency of decisions in approving or denying referral authorizations = ___%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Care Management BPT.pdf, pages 14-18.

Business Capability Model (11 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual activity to accomplish tasks. Primary care provider approves of services by other providers in keeping with state business rules.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. Primary care provider uses an on-line form to authorize the referral.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate.
  4. LEVEL 4SMA automates process to the full extent possible within the region.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of HIPAA and state-specific standards. SMA adopts the Accredited Standards Committee (ASC) X12 278 Health Care Services Review Information transaction.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and regional information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national information exchange.
How easy is it to change the business rules of Authorize Referral?
  1. LEVEL 1Manual rule changes require many business days for approval and implementation.
  2. LEVEL 2Although there may be some automation of standardized business rules definitions, changes and maintenance are labor intensive.
  3. LEVEL 3Adoption of the separation of standardized intrastate business rules definitions from core programming, available in both human and machine-readable formats.
  4. LEVEL 4Adoption of the separation of regionally standardized business rules definitions from core programming, available in both human and machine-readable formats.
  5. LEVEL 5Adoption of the separation of nationally standardized business rules definitions from core programming, available in both human and machine-readable formats.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA collaborates with other regional agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.

Business Capability Quality: Timeliness of Process

How timely is this end-to-end process?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). The Authorize Referral may take many business days to complete.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. The process requires five (5) minutes or less for routine requests. More complex requests may require 30 minutes to review documentation.
  4. LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has regional interoperability. The process requires five (5) minutes or less for routine requests. More complex requests may require 30 minutes to review documentation.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making. Information
  2. LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
  3. LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of regional sources of information. SMA adopts MITA Framework for information exchange by interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework for national information exchange. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in including paper storage and obtains information manually.
  2. LEVEL 2SMA stores information in but automation and HIPAA standards increase accessibility to less than one (1) hour.
  3. LEVEL 3SMA obtains information easily intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is 30 seconds or less.
  4. LEVEL 4SMA obtains information easily interstate agencies and entities. Accessibility is 30 seconds or less.
  5. LEVEL 5SMA obtains information easily national agencies and entities. Accessibility is 30 seconds or less.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of its results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for regional information exchange improving cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving efficiency to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 98% or higher.

Business Capability Quality: Utility or Value to Stakeholders

Does the business process satisfy stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Care Management BCM.pdf, pages 39-45.

Other Care Management processes

Authorize ServiceAuthorize Treatment PlanEstablish CaseManage Case InformationManage Population Health OutreachManage RegistryManage Treatment Plan and OutcomesPerform Screening and Assessment