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 routine referral request is five (5) business 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 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 ext 264 or you may
contact us here.
