What is a direct referral and when does a
direct referral expire? Top
A direct referral is a referral in which the Primary Care Physician (PCP) is delegated the
responsibility to directly refer patients for certain specialty care within the RPN network for selected
services outside of his/her scope of practice. The PCP may refer directly to an in-network specialist for
consultation with or without follow-up visits, or for a service or procedure that does not require prior
authorization. These consultations, services, or procedures are to be performed in an Office, Radiology,
or Laboratory facility contracted with RPN. A direct referral is good for one (1) year.
All referrals that are not direct referrals require prior authorization because they require
determination of medical necessity. UM is the process by which a patient’s clinical picture is
evaluated by a UM Nurse and/or Medical Director using established criteria to evaluate medical services
for necessity and to provide the highest quality of patient care in the most cost-efficient setting.
What is RPN’s turnaround time for
authorizations? Top
The turnaround time for a commercial routine referral request is five (5) business days. The
turnaround time for a senior routine referral request is 14 days. The turnaround time for an urgent
referral request is 72 hours from the time the UM department receives the request. As a reminder, STAT
requests are encouraged to be requested via telephone. Remember, urgent requests are for situations where
the timeframe of a routine determination could seriously jeopardize the life or health of the member or
could jeopardize the member’s ability to regain maximum function.
Why are certain referrals "pended"
for additional information? Top
Critical to maintaining RPN’s turnaround time for referral requests is receiving
absolutely complete authorization requests. Additional information will be requested from the physician
office when requests are sent incomplete (ICD-9 diagnosis codes missing, CPT codes missing, insufficient
clinical information to be able to make a decision, etc.). Sometimes, RPN’s Medical Director will
request to review relevant notes and lab tests. Submission of this information with the referral request
will help with the review process.
How are the tertiary services approved and
directed? Top
All referral requests for tertiary care services go through the UM process meaning they are
reviewed for medical necessity and directed to the appropriate facility by RPN’s Medical Director.
Tertiary care services require significant collaboration with a patient’s health plan to determine
which tertiary care facility the health plan is contracted with, which tertiary care providers are
contracted with RPN, determination and coordination of benefits, and the integration of Case Managers to
follow the patient once they are referred to a tertiary care facility.
The PCP needs to speak to the RPN Hospitalist Physician prior to admitting a patient to the
hospital since the Hospitalist will be following the patient once the patient is admitted. This is the
best way for the Hospitalist Physician to get the PCP’s information & opinions about the
patient’s condition. The RPN Hospitalist Physician for Riverside Community and Parkview Hospitals
can be contacted at 951-788-3370. The RPN Hospitalist Physician for Moreno Valley Community Hospital can
be contacted at 951-601-2363.
Is mental health a carve-out and does mental health
require an authorization? Top
First, let’s define what a carve-out is. Carve-outs are services that are provided by a
specific provider and are not the responsibility of the IPA (RPN).
Mental health (or Behavioral Health) is a carve-out for commercial patients and thus requires
authorization and direction from a patient’s specific health plan for inpatient and outpatient
requests. Refer to the member’s health plan ID card for the telephone number to call for Behavioral
Health benefits.
Senior patients requiring a behavioral health inpatient admission require an authorization from RPN and
thus follow the same UM review process previously mentioned. Senior outpatient behavioral health does not
require an authorization.
The one exception that applies to both commercial and senior patients relates to inpatient admission for
Drug/Alcohol Detoxification. All inpatient admissions for Detoxification require authorization from RPN.
Who are my key contacts at RPN for
operational questions? Top
General questions should be directed to the Provider Relations Director at 951-788-9800, ext
264 or you may contact us here.
