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Referrals and Authorizations Flashcards

1
Q

What is a referral?

A

A referral is used to track events where a provider sends a patient to another physician for the purpose of specialized diagnostic assessment and treatment.197

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2
Q

What is authorization?

A

An authorization tracks authorization information from payers. Authorization staff communicate with payers to secure authorization numbers and make sure the numbers appear on the claims to avoid denials.197

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3
Q

What is an Authorization/Certification?

A

When a patient’s insurance place requires authorization for an inpatient stay or surgery, a special kind of authorization called an authorization/certification (auth/cert) is necessary. The auth/cert is the process of calling the insurance company to obtain authorization for treatment. 197

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4
Q

What is the core of referrals, authorizations, and encounters?

A

Fundamentally, the core concern regarding referrals, authorizations, and encounters is whether an encounter was authorized.199

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5
Q

What is an epic-released report that gives you information about prior authorization?

A

It is the encounters requiring an Authorization data model and it allows users to report on prior authorization rates at your organization. 199

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6
Q

What does the table VisitFact.AuthorizationStatus Reflect?

A

It reflects whether a visit has been authorized. The column stores the authorization status of a visit by evaluating all the authorizations linked to an appointment and stores values like authorized, not authorized, and authorization not needed.199

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7
Q

Is the AuthorizationStatus in VisitFact?

A

True 199

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8
Q

What happens if a visit need authorization?

A

If a visit needs authorization, then it needs to have at least one linked referral, and all of its linked referrals must be authorized for the encounter to be authorized.199

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9
Q

What happens if the visits does not need authorization?

A

If the visit doesn’t need authorization, the system will still check for any linked referrals. Any such referrals must be authorized. If there are no linked referrals, the encounter authorization status is “Authorization Not Needed.”199

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10
Q

What can I do to link visits to referrals?

A

If you need details about the referrals that contribute to VisitFact’s AuthorizationStatus column, use the VisitReferralMappingFact table to link the visits to the referrals 199

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11
Q

How do referrals appear in Chronicles?

A

Referrals appear as RFL records in chronicles.

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12
Q

What table would I use for referrals?

A

ReferralFactReferrals reporting can be quickly summarized with one statement: use ReferralFact. This table also forms the core of the Referrals data model in SlicerDicer.201

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13
Q

True or False:Referal Fact is used in SlicerDicer?

A

True, it forms the core of the referrals data model in Slicerdicer. 201

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14
Q

What does the referrals data model report on?

A

The referrals data model allows users to report on referral activity, including referral patterns, and key metrics like referral cycle times and completion rates. 201

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15
Q

What is a referral?

A

Referrals are peer to peer referrals where providers write an order for a patient to receive care from another provider. 201

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16
Q

What are authorizations?

A

Authorizations exist for anything that must be authorized, which can include high-value threatments.

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17
Q

What is the different between a referral versus an authorization?

A

Conceptually, referrals are peer‐to‐peer referrals where providers write an order for a patient to receive care from another provider. Authorizations exist for anything that must be authorized, which can include high‐value treatments. They are not mutually exclusive. If a referral is for an expensive procedure that requires preauthorization, clinical users at your organizations will likely call it a referral, and authorizations staff will treat it as an authorization; in other words, it is both a referral and an authorization.
Practically, if a requester is focused on where we are referring patients to, they are primarily concerned with referrals. If the requester is focused on tracking authorization rates or authorization‐related denials, they are primarily concerned with authorizations. 196

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18
Q

If a requester is focused on where we are referring patients to they are primarily concerned with what?

A

Referrals 201

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19
Q

If the requester is focused on tracking authorization rates or authorization-related denials, they are primarily concerned with what?

A

Authorizations 201

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20
Q

What is service level authorization?

A

t is possible for a coverage to grant authorizations at the level of each procedure, each date range of care, or the combination of both associated with the RFL record. This is known as service‐level authorization (SLA). SLA has special functionality that automatically finds the charges associated with the procedure that was the cause of the SLA, and then tracks the coverage’s authorization for those charges.

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21
Q

What is the ReferredByProviderDurableKey?

A

Provider who placed the referral 201

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22
Q

How do organizations define unique values that appear as referrals?

A

Typically, organizations define unique values in RFL 430 which appears as ReferralFact.Type201

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23
Q

How does the REF master file store records?

A

The Referral Source REF master file stores a record for each entity that may refer patients. Examples include physicians who write medical referrals and marketing sources by which you acquire new patients. 202

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24
Q

How would you connect the referring provider to the referral?

A

The referring provider field stores the REF record ID. In Clarity, this requires that you link from REFERRAL.REFERRING_PROV_ID to REFERRAL_SOURCE.REFERRING_PROV_ID. Once in REFERRAL_SOURCE, the REF_PROVIDER_ID column stores the corresponding SER record ID.202

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25
Q

What does ReferralFact.Class mean?

A

Class of referral. 203

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26
Q

What does a referral’s class indicate?

A

A referral’s class indicates key information about its origin and destination. 203

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27
Q

Draw examples of incoming, internal, and outgoing referrals

A

draw 204

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28
Q

Explain community Connect

A

Community Connect allows accredited organizations with a track record of success to extend their EHR to
create a shared patient record, enhance a strong regional relationship, or become a host for satellite
facilities across the country and world. Commonly, Community Connect customers create a shared record
with practices and small hospitals in their area with which they share patients. In other words, Community
Connect customers and their Connect sites share one instance of Epic 204

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29
Q

A connect site refers a patient to the host. what would this referral’s class be?

A

Internal 204

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30
Q

What is network retention

A

Network retention is a KPI that answers how many referrals are in-house:From one of your providers to another of your providers. Maximizing retention is important for saving time and money for both your organization and your patients. 205

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31
Q

What does it mean when a referral is leaked?

A

A referral is leaked if the referred-to provider is not in a preferred network level.205

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32
Q

In the Isleaked column what does a 1 mean and what does a 0 mean?

A

1 returns if the referral is considered leaked, 0 if the referral is considered retained, and Null otherwise.

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33
Q

What does the VisitReferralMappingFact table do?

A

Remember that the VisitReferralMappingFact table maps the relationship between visits and referrals. 205

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34
Q

For the referralFact.FirstEncounterKey, what is the purpose?

A

It is the first encounter associated with the referral. For Epic data, this is the earliest encounter associated with the referral.206

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35
Q

What does the ReferralFact.LinkedToAnEncounter column mean?

A

1/0 column that indicates whether the referral is associated with an encounter. This column returns 1 if the referral is associated with at least one encounter and 0 if the referral is not associated with an encounter. 206

36
Q

What does the ReferralFact.IsComplete column do?

A

1/0 column that indicates whether the referral is considered complete. This column returns 1 if the referral is complete and 0 if the referral is not considered complete.

37
Q

What does the column ReferralFact.IsLoopClosed?

A

1/0 column that indicates whether the loop is closed for the referral. This column returns 1 if the loop is closed and 0 if it is not. 206

38
Q

Do the columns LinkToAnEncounter, IsComplete, IsLoopClosed reflect encounters that your instance of epic creates?

A

These columns only reflect encounters that your instance of Epic creates. If the referral is to
an organization not on your instance of Epic, these columns will not reflect whether an
encounter was scheduled or completed as a result of the referral. 206

39
Q

True or False: In Epic, does authorization exist at the same level?

A

False, authorization exists at different levels 208

40
Q

What is Referral in authorizations?

A

Referral‐level authorization may be represented by the single status attached to the RFL record 208

41
Q

In the authorization section, what is coverage?

A

Coverage-level authorization describes a single decision by a coverage. 208

42
Q

In authorizations what is service?

A

It is service level authorizations (SLA
) that describe a coverage’s decision for each procedure or time range of care. 208

43
Q

What is auth/cert authorization?

A

It describes a coverage decision for inpatient or surgery care. 208

44
Q

What is an authorization number?

A

An authorization number indicates a payer’s agreement to pay and is captured in the AuthorizationFact.AuthotizationNumber. 208

45
Q

True or False: Is it possible for coverage to grant authorizations at the level of each procedure?

A

Yes, it is possible for a coverage to grant authorizations at the level of each procedure, each date range of care, or the combination of both associated with the RFL record. This is known as service-level authorization (SLA) 208

46
Q

True or False: SLA has a special functionality that finds charges with procedures?

A

True, SLA has a special functionality that automatically finds the charges associated with the procedure that was the cause of the SLA, and then tracks the coverage’s authorization of those charges. 208

47
Q

Each Service Level Authorization (SLA) appears in epic as what?

A

Each SLA appears in Epic as an AUT record.208

48
Q

What is the granularity of AuthorizationFact?

A

The granularity of AuthorizationFact has one row for each SLA that has an authorization number, and for each SLA, it describes the coverage, procedure, authorization number, and more. 208

49
Q

What is the primary table to report on authorizations?

A

The primary table used to report on these authorizations is AuthorizationFact.208

50
Q

When will AuthorizationFact store rows for coverage-level authorizations?

A
  1. The coverage provides an authorization number for the entire RFL record.
  2. The record is not an Auth/Cert
  3. The coverage has no SLAs that have authorization numbers for this record. 209
51
Q

What does it mean when you see coverage level authorization in the AuthorizationFact table?

A

whenever you see a coverage level authorization in this table, you know that the coverage provided an authorization number for the entire record and did not offer SLA information. 209

52
Q

If an RFL record status was ever set to authorized, and no lower-level authorizations exist for the RFL record, what happens to the rows in AuthorizationFact?

A

It gets one row 209. If a referral has a referral-level authorization in AuthorizationFact, then it only tracked authorization at the referral level.

53
Q

What is auto status assignment ASA

A

Many organizations use auto status assignment ASA, a process of building rules to automatically determine the referral-level authorization status. A common request is to quantify how much less work is necessary due to ASA versus users manually evaluating the referral status. The AuthorizationFact.AuthorizedThroughAutoStatusAssignment column, which stores a 1 if ASA approved the row in question and a 0 otherwise, helps with those calculations. 209

54
Q

What is the Granularity of ReferralFact?

A

Referralfact includes one row for non-auth/cert referral, regardless of what levels are associated with the RFL record. 210

55
Q

True or False” ReferralFact can obscure the full authorization information associated with a referral?

A

True 210

56
Q

What is the referral cycle time?

A

The referral cycle time measures how efficient an organization is at processing referrals and quickly seeing patients referred to them. 210

57
Q

What tables in caboodle and clarity can you use for referral cycle time?

A

In caboodle, you can use referralFact it offers many columns that relate to cycle time, including CreationToScheduledate and CreationToFirstAuthorization. Even better, these columns use a unit of business days. In clarity, the V_Referral_Cycle_Time view offers similar ease of reporting for referral cycle time.

58
Q

What do auth/Cert records collect?

A

Auth/Cert records collect authorization numbers from insurance for inpatient and surgery situations.210

59
Q

How do Auth/Cert records exsist?

A

They exist as RFL records in chronicles.210

60
Q

How does AuthrizationFact store data?

A

AuthorizationFact stores a row for each combination of auth/cert and coverage.

61
Q

What elements does AuthorizationFact track?

A

AuthorizationFact tracks the most important elements for auth/certs, including the authorization status, authorization number, and the span of time the payer has authorized. 210

62
Q

Tell me the difference between the caboodle tables ReferralFact and ReferralEventFact versus the Clarity table AuthorizationFact.

A

The ReferralFact and ReferralEventfact tables exclude auth/certs, while the authorizationFact table includes auth/certs. 210

63
Q

What is Real Time Authorization (RTA)

A

It is an epic functionality by which healthcare organizations interface with insurance to automatically authorize care in real time, thereby saving time, money, and effort. 211

64
Q

How would you find relevant auth/cert records for patient contacts and
HARs?

A

You would report from Pat_enc_5 and HSP_account

65
Q

What are bed days?

A

When a payer approves a hospital stay, the payer approves a number of days. 212

66
Q

Auth/Certs track bed days, what are the 3 major types?

A

Approved-The payer plans to pay for the services of the bed.

Denied- the payer does not plan to pay for the services of the day.

Avoidable- A bed day that the case manager believes was unnecessary for medical care. This bed day may still be considered approved or denied by the payer. 212

67
Q

What is the differences between Referral_cvg_bed and Referral_bed_day tables in clarity?

A

Basic information on the bed days the payer approves appears primarily in the Clarity table
REFERRAL_CVG_BED. If the bed days are instead recorded without identifying any payer to approve the
bed day, they appear in the Clarity table REFERRAL_BED_DAY. 212

68
Q

Tell me about Referral_CVG_BED? What is the granularity and notes on it.

A

One row for each coverage’s summary of bed days for an auth/cert. Details on each set of bed days exist in separate related-multi tables. The order of the coverages does not necessarily reflect the current filing order of the auth/cert. 213

69
Q

Tell me about Referral_Bed_Day. What is the granularity? Tell me the notes on it.

A

The granularity is one row for each classification of bed days for an auth/cert. Classifications are customizable by organization. this table is particularly relevant for patients who have no coverage. 213

70
Q

Referral

A

A referral is used to track events where a provider sends a patient to another physician for the purpose of specialized diagnostic assessment and treatment.

71
Q

Referral Class

A

A referral’s class indicates key information about its origin and destination. You have 3 different referral classes which are incoming, internal, and outgoing. 203-204

72
Q

Referral leakage

A

A Referral is leaked if the referred to provider is not in a preferred network level. In other words it means that the referral is to a non-preferred location. 205

73
Q

Closed Encounters:

A

A closed encounter is when we know that the loop is closed and the referring provider was provided feedback on the care the patient got from the specialist. The LinkedToAnEncounter, IsLoopClosed, columns indicate what care the associated encounter provided. These encounters only reflect encounters that your instance of Epic creates. I the referral is to an organization not on your instance of Epic, these columns will not reflect whether an encounter was scheduled or completed as a result of the referral. 206

74
Q

Referral Cycle Time

A

referral cycle time measures how efficient an organization is at processing referrals and quickly seeing patients referred to them. 210

75
Q

Authorization

A

An authorization tracks authorization information from payers. The purpose is to secure authorization numbers and make sure the numbers appear on the claims to avoid denials. 197

76
Q

SLA

A

Service Level Authorization or SLA describes a coverages decision for each procedure or time range of care. 208

77
Q

Auth/Certs

A

The purpose is when a patient’s insurance plan requires authorization for an inpatient stay or surgery, a special kind of authorization called an Authorization/Certification. This Is the process of calling the insurance company to obtain authorization for treatment. 197

78
Q

Link visits to their Referrals

A

If a visit needs authorization, then it needs to have at least one linked referral, and all of its linked referrals must be authorized for the encounter to be authorized. 199
The VisitReferralMappingFact table maps the relationship between visits and referrals. The FirstEncounterKey, LinkedToAnEncounter, ISComplete, and the ISLoopedClosed all help with understanding the link between a visit and a referral. Now, these columns only reflect encounters that your instance of epic creates. If the referral is to an organization not your instance of Epic, these columns will not reflect whether an encounter was scheduled or completed as a result of the referral 205-206

79
Q

Determine the authorization status of a visit

A

The VisitFact.AuthorizationStatus reflects whether a visit has been authorized. As this column is in VisitFact, it is limited to visits, and it wouldn’t be applicable to hospital admissions. This column stores the authorization status of a visit by evaluation all the authorizations linked to an appointment and stores values like authorized, not authorized, and authorization not needed.

80
Q

Determine what authorization exist at which levels for a referral

A

Authorization exists at different levels. Referral-level authorization may be represented by the single status attached to the RFL record. Coverage-level authorization describes a single decision by a coverage. Service level authorization describes a coverages decision for each procedure or time range of care. Auth/cert describes a coverage’s decision for inpatient or surgery care. 208

81
Q

Determine the authorization status or authorization number for each level of authorization.

A

An authorization number indicates a payers agreement to pay and is captured in AuthorizationFact.AuthorizationNumber. 208

82
Q

Determine the pre-certification status of an auth/cert.

A

Auth/Cert records collect authorization numbers from insurance for inpatient and surgery situations. For reporting on auth/cert we would be using AuthorizationFact because it stores authorization status, authorization number, and the span of time the payer has authorized. 210

83
Q

The differences among incoming, internal, outgoing, and leaked referrals

A

A referral class indicates key information about its origin and destination. There are 3 classes which are incoming, internal, and outgoing. Incoming is when and outside clinic or hospital makes a referral the our place of service. Internal is when the entity makes an internal referral such as OBGYN to dermatology. Outgoing is when our current place of service makes a referral to an outside entity. A leaked referral is when a referral is make to a non preferred location. And this is measured in the ReferralFact.Isleaked with 1 being leaked. 205

84
Q

The context behind the referral cycle time columns of ReferralFact

A

Referral Cycle time measures how efficient an organization is at processing referrals and quickly seeing patients referred to them. ReferralFact offers many columns that relate to cycle time, including CreationToScheudleDate and CreationToFirstAuthrization. These columns use business days. In clarity the V-Referral_Cycle_Time view offers similar ease of reporting for referral cycle time. 210

85
Q

The differences across the different levels of authorization

A

In Epic authorization exists at different levels and are referral, coverage, service, and auth/cert. Referral and coverage level authorizations provide a broad overview of the authorization status, SLA and auth/cert provider deeper tails ensuring that specific services or procedures are coveraged.

Referral level authorization is generally the least important because it does not reflect coverage specific authorization. Referral level authorization is usually represented by the single status attached to the RFL record. (This is the most basic form of authorization) 209-209

Coverage level authorization is a single decision by a coverage providing approval or denial of a referral. This authorization is tracked in the RFL Masterfile and be rows for coverage level authorization in the authoerizationFact table (only if the coverage has no SLA that have authorization numbers). If you see coverage level authorization in the autherizationFact table that means that there is an authorization number and did not have SLA information. (It is more detailed than referral level authorization, focusing the broader decision made by the coverage provider but still not detailing specific services) 208-209
Service level authorization is when you have authorization for each procedure, each date range of care or the combination of both associated with the RFL record. One can think of this as coverages decisions for each procedure or time range of care. This would be part of the AUT master file. (This one is even more granular, detailing a coverage providers decision) 208

Auth/Cert describes a coverages decision for inpatient or surgery care. This type of authorization collections authorization numbers from insurance for inpatient and surgery situations. This exist as RFL records in chronicles. Since an auth/cert can capture the insurance information for multiple coverages related to a stay, authorizationFact stores a row for each combination of auth/cert and coverages related to a stay. (This specifically describes the providers decision for inpatient or surgical care because the provider is contacting the insurance company to obtain authorization-mandates prior approval for such services) 210

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