Providers submit referral requests to ND MMIS primarily when a primary care provider in a managed care program is requesting that a member enrolled in the ND Medicaid program see another specialist or provider outside of the member's assigned PCP. You use the Referral pages to search, add, and edit referral requests.
Note: A service authorization may also be required at the time the referral is requested, depending on the benefit plan requirements for the service being requested. Those are managed using the Service Authorization function of Claims.
Providers can submit referral requests a number of ways, including through the provider Web portal, X12 278 electronic transactions, and hardcopy by fax or mail. You enter hardcopy referral requests, received by fax or mail, into ND MMIS manually using the Referral page.
Once a referral request enters ND MMIS, you manage it using the Referral page. You can address exceptions, update header and line item status, override the location/user assigned to the referral request, and add and view attachments. Attachments can include images of letters sent to and received from providers or members, and supplemental documents received from the provider that are related to the referral request.
You can also set up alerts (or reminders) for future events such as a referral expiration. On the date you establish, ND MMIS posts an alert to the appropriate user's My Tasks panel that indicates the reason for the reminder.
During claim adjudication, ND MMIS analyzes each claim received to determine if the use of this provider requires a referral. If the claim requires a referral, ND MMIS analyzes the referral records to determine if an approved referral request for the claim exists. Once found, the claim is updated with the approved referral request information. The referral request is updated to note each time a claim is applied to a referral line item.
Referral (Referral ID Tab) Page
Referral (Referral Type Tab) Page
Referral (Search Results) Page
What Is Service Authorization?
Version as of 5/16/14.
Copyright © 2017 Conduent, Inc. All rights reserved. Conduent and Conduent Agile Star are trademarks of Conduent, Inc. and/or its subsidiaries in the United States and/or other countries.