90-Day Referral Completion - Exploratory Tip Sheet
The percentage of members who completed their initial referral from a PCP to a specialist within 90 days.
In 2021, the referral completion is an Exploratory Measure, and will not qualify for payment. Data will be available quarterly for providers to track their member’s compliance in 2021. The Alliance is reviewing this measure for consideration for payment in 2022. For additional information refer to the 2021 CBI Tech Specifications.
All Medi-Cal members who are continuously enrolled for four consecutive months are eligible. Members must be linked to a PCP at the time of the initial visit with the specialist to qualify for this measure.
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.