Questions Submitted by the Public, by Date Posted to the Website. Referral authorization in shared information systems


All providers in our medical care program use a commonly owned and operated information systems infrastructure. The routing process for consultations and referrals between and among our practitioners occurs within a single application or as part of the electronic medical record system. The communications among these clinicians for consultations, and the arrangements that are made to facilitate patient appointments with our specialists, is a workflow management process. No certification or authorization is required to provide care or conduct referrals and no payment decisions are made on the basis of these communications. Does this process constitute a standard transaction under §162.1301 - Referral Certification and Authorization Transaction?


Under § 162.1301, the referral certification and authorization transaction is any of the following transmissions:

(a) A request for the review of health care to obtain an authorization for the health care.

(b) A request to obtain authorization for referring an individual to another health care provider.

(c) A response to a request described in paragraph (a) or paragraph (b) of this section.

This definition (at paragraphs (a) and (b)) implies that someone is asking for authorization to provide certain health care or make a specific referral because the authorization is required to secure payment for the care or referral. The mere scheduling or routing of clinical information from one provider to another for care or referral purposes, where authorization of the care or referral is not being sought for payment purposes, would not meet this definition and would not be required to be conducted as a standard transaction.