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90-Day Referral Completion – Exploratory Measure Tip Sheet
The percentage of members who completed their initial referral from a PCP to a specialist within 90 days.
This is an exploratory measure; there is no payment for 2021 and 2022. For additional information, refer to the 2021 and 2022 CBI Technical Specifications.
Data for this measure will be collected via claims with the referral number submitted by the specialists. All referral claims must include the following data fields:
- Member ID
- Member’s full name
- Member’s date of birth
- PCP’s group NPI
- Referral number on claim
Denied claims and denied referrals will be excluded from this measure.
- Map your referral tracking system process in detail.
- Develop written policies and procedures to include all definitions, workflows, roles and responsibilities, and reporting.
- Stratify referrals as urgent or routine, and develop protocols for each.
- Dedicate non-clinical staff (MAs, LPNs, LVNs) to act as referral coordinators.
- Make sure the specialist has accurate information, prior to the member’s visit.
- Ensure your clinic receives and acknowledges all notes and results from the specialist.
- Develop a relationship with your specialist referral network to build trust and develop shared expectations for referrals.
- Document patient declined referrals and include a statement in the patient chart indicating “Patient declines referral/test/procedure after verbalizing understanding of risks, benefits, alternatives and consequences of failing to complete the referral/ test/procedure.”
- Utilize your EHR system to track referral orders. Train staff to enter orders according to your standards.
- Follow the American College of Physicians (ACP) PCP Referral Request: Brief Patient Education Guide for a patient-centered referral.
- Explain the reason for the recommended referral to the member, and if applicable to the patient’s care giver/partner (Example. Use the “teach back” technique to improve member understanding).
- Make the member involved in the process of choosing the appropriate referral to the clinician (Example: ability to speak the patient’s preferred language).
- Make clear how the appointment is to be arranged.
- Discuss any potential barriers that may interfere with the appointment and possible solutions (Example: for transportation concerns refer patients to the Alliance’s Transportation Coordinator at 1-800-700-3874 ext. 5577).
- Discuss any needed patient activities prior to the appointment (Example. Additional tests or procedures, including how to obtain them).
- Consider additional suggestions that may help ensure a patient and family centered referral (Example: suggest the patient compose a list of questions they want the referred specialist to address)
- For additional resources, see the ACP High Value Coordination Toolkit.
Referral Process Workflow