Exhibit U_MHS Genesis RM 2.0 Referral Management Guide.pdf

MHS GENESIS RM 2.0

Referral Management Guide

Developed By:

Defense Health Agency Referral Management Work Group (September 2023; Version 8.0)

DHA Referral Management Work Group

DHA NCR Healthcare Ops List MHS Referral Management WG dha.ncr.healthcare-ops.list.mhs-referral-management-wg@health.mil

Annex to DHA Interim Procedures Memorandum 18-001, Standard Appointing Processes, Procedures, Hours of Operation, Productivity, Performance Measures and Appointment Types in Primary, Specialty, and Behavioral Health Care in Medical Treatment Facilities (MTFs)

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Table of Contents Introduction to Referral Management 2.0

Section 1: Setting Up Worklists

Creating a Worklist:

Section 2: Standardized Enterprise Centralized RMC Referral Process Processing (Centralized IRMAC Model)

Referral Review Process (RMC/IRMAC)

Appointing (Accepting) Referral to the MTF

Defer Referrals to the Private Sector/Network (MCSC)

OHI Referral Processing

Referrals Requiring More Information

MTF to MTF Referral Processing

MTF Referrals Requiring Closure and Reorder

Scheduling Initial Referral

Section 3: Processing Rejected Referrals

MCSC Rejected Referrals

Rejected by the MCSC/Referral Can Not be Resubmitted via MHSG

Rejected by the MCSC/Referral is resubmitted via MHSG

SEND/FAILURE

Section 4: DOD/VA Sharing Agreement Referral Request

Accept VA/DOD Referral

VA/DOD Referral Upload Referral Packet

Section 5: Right of First Refusal (ROFR) Referrals

Accept A ROFR

Reject a Previously Accepted ROFR Referral

Section 6: Clinic Review/Clinic Book/ De-Centralized Worklists

Clinic Referral Review Process (De-Centralized)

Ordering Provider Clinical Staff Worklists:

Ordering a Referral (Provider Role)

Reject a Previously Accepted ROFR Referral

Section 7 : Referral Tracking

Direct Care: Close the Loop Process (CLP)

Direct Care: Notifying the Ordering) Provider of MTF Specialty Results

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Private Sector Care: CLRs

Private Sector: Upload CLR with a MHSG Referral Case

Private Sector: Upload a CLR Without a Referral Case

Closing Referrals and Updating Referral Status/Substatus

Section 8: Message Center

Notifying Provider via Message Center

Creating .Phrases

Direct Messaging for Referral Management

Sending Direct Messages

Reviewing Received Direct Messages

Section 9: Referral Reports

All Referrals Report 2.0

Referral Clear and Legible (CLR) Report

Referral Audit Report

Section 10: Faxing from MHS GENESIS

The first steps are setting up provider letter

These steps are required only when initially setting up preferences

Faxing

Faxing from Documentation

Section 11: References

Referral Reminders

RM 2.0 Case Status and Substatus Mapping

How to manually update referrals

Policies and Regulations

MHSG Links

Radiology Order Convert to Referral Process

Glossary

Terminology and Acronyms

Section 12: FAQs

Defer to Network Referrals (External Referrals)

Closing the Loop

Worklist TIPs and Other Issues:

MEDICAL SERVICE (SPECIALTY) CODE SET

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Introduction to Referral Management 2.0

The purpose of the Military Health System (MHS) GENESIS Referral Management (RM) 2.0 Guide is to provide detailed instructions on how to execute the most common RM processes in MHS GENESIS (MHSG) in accordance with the policies and procedures in Defense Health Agency (DHA) Interim Procedure Memorandum (IPM) 18-001. These RM processes have been standardized to provide an overall optimized user experience within the Integrated Referral Management and Appointing Center (IRMAC) model for all Military Treatment Facility (MTF)/Market sizes. It is the expectation that all MTFs/Markets on MHSG will follow these referral processes. The objectives of RM are to account for all referrals; to ensure patient safety; to

MHSG RM 2.0 Referral Management Guide V8 5 provide a positive patient experience; to optimize the direct care capabilities; and to efficiently execute RM workflows.

If a site would like to suggest an updated or new process, it should be brought to the MTF’s Informatics Steering Committee Chair to submit a GSC ticket. The ticket will route to the Business Functional Champion and the DHA Referral Management community for review and consideration. If the change is accepted, the appropriate workflow will be utilized to perform any required testing, update the system configuration, document the changes in this user guide, and communicate the changes to the MTF functional users.

MHS GENESIS RM 2.0 Roles

MHS GENESIS SYSTEM

ROLES

DESCRIPTION/RESPONSIBILITES

Referral Management

All referral management center (RMC) staff need the Referral Management (RM) role in MHSG RM 2.0. This role allows the RMC staff to: review, disposition, and schedule referrals; monitor and track referrals; upload private sector care clear and legible results (CLRs) into MHSG; and close referrals per policy. Only RMC staff will receive the RM role.

This role allows the user to enter Right of First Refusal (ROFR) and DOD-Veteran Administration (VA) Resource Sharing Agreement (RSA) referrals without a provider co-signature. Per DHA policy, the only referral the RM staff may order are ROFRs.

Referral Admin

Staff who appoint/schedule specialty care appointments, clinical staff who review referrals, and clinical staff who close the loop will need the Referral Admin (RA) role

Section 1: Setting Up Worklists

Assumptions:

Referral activities identified in this section are conducted in MHS GENESIS using the Referral Management or Referral Admin system role.

All users must have a valid CAC.

This section discusses the purpose and functionality of worklists, delineates steps to creating worklists, and provides specific mandatory RM worklists. It also provides other recommended worklists for clinical staff and for the Close the Loop process.

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Creating a Worklist:

How to create a worklist in Powerchart:

Worklists provide a summary view of referrals based on the user’s selected filters creating a “to do” list. The same worklists are viewable in both Power Chart and Revenue Cycle.

The number of worklists the user creates will depend on multiple factors: centralized or decentralized referral review model, RM/RA role, task to be completed in RM process, market size, etc.

Some users will prefer one worklist that captures all statuses of the referral and others will prefer targeted lists. The worklist is scalable to the user’s needs and preferences.

Each user will have to create their own worklist because worklists cannot be shared among users.

The system defaults to all if no selection is made.

1. Navigate to Referral Management in Power Chart or View in Revenue Cycle

2. Click List Maintenance

3. Click “Add” button. Yellow highlighted and red asterisks means the field is mandatory and the user must fill in the blank field or make a selection.

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4. Name Worklist. There are standardized worklists all MTFs/Markets RM staff must use

(defined in next section).

5. Select Type: Note the “Type” defaults to “Originating”. There are 3 types of worklists:

Originating, Receiving, and Centralized. The type of worklist selected will drive what filter criteria selection you can view. It also impacts the options you have when changing the status of the referral from its current status to another status.

Originating worklists show referrals from the ordering provider/location which need to be dispositioned to the MTF, to another MTF, or to the network.

Receiving worklists are for receiving the referral for accepting or rejecting in the MTF/specialty clinic (Refer To Provider) and for scheduling the referral.

Centralized worklists combine functionality of the above two types of worklists; users can disposition, accept, and schedule referrals from the same worklist.

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6. Refer From Location: This is a mandatory field as evidenced by the *. Select the DMIS

ID/MTF originating the referrals. If you work in a Large Market, you may need to select multiple MTFs.

7. Refer From Provider: This is the provider(s) who wrote the referral.

8. Medical Service: The medical service is also known as the medical specialty.

9. Status: The current status of the referral. Select status appropriate for the worklist. NOTE: Be sure to include all applicable sub statuses required for the worklist.

10. Priority: The clinical priority of the referral.

11. Referral Type: Default to all.

12. Refer To Location: The location referral is routed.

13. Refer To/From Provider: The provider referral is routed or provider who placed the order.

14. Dates: Dates to be included on the worklist

15. Assignment: Referrals assigned to specific staff members (Not operational at this time)

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Standardized RM/IRMAC Worklists

Standardized Enterprise Centralized IRMAC Worklists (Mandatory). Standardized worklists reflect workflows that all RM staff perform. Therefore, these enterprise worklists will use the mandatory standardized naming conventions below for common reference and ease in troubleshooting worklists. If there is a workflow that does not apply, MTF, it is not required to create the worklist. For example, if the MTF/Market does not do Right of First Refusal (ROFR) referrals, then ROFR Results Tracking worklist would not be required. Additional worklists specific to the MTF/Market workflows are optional.

New Referrals to be Dispositioned. All RM staff require this worklist to review, coordinate, and disposition referrals.

DME/Home Health Referral Processing: Use this worklist to process, track and close referrals that do not require CLR chasing.

Rejected Referrals. Use this worklist to view all referrals rejected by the MTF’s specialty clinic, by another MTF on MHSG, or by the MCSC. The reason for the rejection from the MCSC will be in the “Comment” tab of the referral case. The specialty clinic’s reason for rejection will appear next to the status and should be noted on the comment tab. This is your list to 1.) identify referrals that need to be deferred to the network or to be sent to another MTF on or not on MHSG and, 2.) review and action referral rejected by the MCSC.

MTF to MTF Referrals. Use this worklist to send referrals to another MTF on MHSG. Generally, the receiving MTF is not in your Market. For example, Bassett ACH sending to Madigan AMC;

Laughlin AFB sending referral to the San Antonio Market. Use the receiving MTF’s RM practice location. These start with the DMIS + Base Name. For example, 7379 DHA San Antonio Market Referral Management Center.

ROFR/VA Results Tracking. Use this worklist to track ROFR, DOD/VA RSA and external (referrals from MTFs not on MHSG) referrals seen in the MTF to ensure the MTF specialty results are sent to the Refer from civilian provider.

Pending Acceptance Referrals Use this worklist to view all referrals sitting in a MTF specialty clinic worklist, waiting to be Accepted or Rejected. Per DHA policy, MTFs have one business day to disposition a referral (Accepted or Reject). RMCs must monitor in clinic worklists and disposition per policy.

Received Status Referrals. Use this worklist to track referrals that are “stuck” in a Received status greater than 5 business days. This is an error in the system and is being actively worked.

Until fixed, MTFs must monitor these referrals. These referrals may be awaiting action on your part such as additional information before the MCSC can process the authorization. These referrals may already have been authorized (“Certified”) or (“Not Certified” (denied)) in the MCSC portal and MHSG has not updated the status.

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RMC/IRMAC WORKLISTS

Worklist Name Type and Filters (no selection defaults to all)

R M

C

/IR

M A

C

New Referrals to Be Dispositioned

Type: Centralized

*Location: MTF Locations originating referrals Refer From Provider: No selection: system defaults to all Refer to Provider: No selection: system defaults to all Medical Service: If processing specific medical services make those selections here. If processing all medical services do not select any Status: Not Started; Prepare Send Priority: No selection: system defaults to all Referral Type: No selection: system defaults to all Dates: Select as needed: system defaults to all Assignment: No selection: system defaults to all

R M

C

/IR

M

Rejected Referrals

Type: Originating

*Refer from Location: MTF Locations originating referrals Refer From Provider: No selection system defaults to all Medical Service: No selection system defaults to all Status: Rejected – No Substatus; SEND_FAILURE Priority: No selection: system defaults to all Referral Type: No selection: system defaults to all Refer to Location: No selection: system defaults to all Refer to Provider: No selection: system defaults to all Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

R M

C

/IR

M

DME/Home Health Referral Tracking

*Refer From Location: Select MTF Refer From Provider: No selection: system defaults to all Medical Service: Durable Medical Equipment; Home Health Status: Received; Rejected/No Substatus Only; Certified Priority: No selection: system defaults to all Referral Type: No selection: system defaults to all Refer to Location: Defer to MCSC electronically, DoD (triggers a 278 sent to the MCSC); Defer to MCSC via Manual/eFax, DoD Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

R M

C

/IR

M

MTF to MTF Referrals to be Dispositioned

Type: Receiving

*Refer to Location: Select the “XXXXA-REFERRAL” Refer to Provider: System defaults to all Medical Service: System defaults to all Status: Not Started, Prepare Send, Pending Acceptance Priority: System defaults to all Referral Type: System defaults to all Refer from Provider: System defaults to all Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

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R M

C

/IR

M

ROFR/VA Results Tracking

Type: Originating

Refer from Location: Select the “XXXXA-REFERRAL” location Refer from Provider: Unavailable, Physician Medical Service: System defaults to all Status: Accepted, Scheduled, Patient Seen Priority: System defaults to all Referral Type: System defaults to all Refer to Location: System defaults to all Refer to Provider: System defaults to all Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

R M

C

/IR

M

Pending Acceptance Referrals

Type: Centralized

Refer from Location: Select MTF Refer from Provider: System defaults to all Medical Service: All medical services monitored by IRMAC Team.

Status: Pending Acceptance Priority: System defaults to all Referral Type: System defaults to all Refer to Location: System defaults to all Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

R M

C

/IR

M A

C (A

PP

O

IU

N

TI

N

G

Appoint to MTF Referrals

Type: Centralized

*Location: Select your MTF locations or specific clinics in your MTF as needed.

Refer From Provider: No selection: system defaults to all Medical Service: System defaults to all. You may also select specific PLs/specialties as appropriate.

Status: Accepted, Pending Reschedule Priority: No selection: system defaults to all Referral Type: No selection: system defaults to all Refer to Location: No selection: system defaults to all

Assignment: No selection: system defaults to all ll

Assigned to Me *Location: Select your MTF locations or specific clinics in your MTF as needed.

Refer From Provider: No selection: system defaults to all Medical Service: System defaults to all.

Status: No selection: system defaults to all Priority: No selection: system defaults to all Referral Type: No selection: system defaults to all Refer to Location: No selection: system defaults to all

Assignment: Search for name and select

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Section 2: Standardized Enterprise Centralized RMC Referral Process Processing (Centralized IRMAC Model)

Section Overview: This section provides instruction for MTFs/Markets that are Centralized IAW DHA IPM 18-001 and provides a standardized approach for reviewing and dispositioning referrals. Instructions for obtaining additional information and modifying the referral case are also included within this section.

After reviewing the Referral Case to ensure all fields are consistent and no additional information is needed, the Centralized IRMAC staff will make one of the following decisions (dispositions) for all referrals that are centrally managed:

• Appoint the referral case to a specialty clinic within the MTF or Market.

• Redirect the referral case to another MTF.

• Redirect to a specialty clinic based on your MTF/Market booking protocols/standard referral guidelines.

• Defer to private sector care based on capability and capacity report for MTF or Market.

• Close the referral case (reason required)

In PowerChart, go to the Referral Management MPage by clicking on the “Referral Management” button in the toolbar or clicking “View” and select “Referral Management.”

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Referral Review Process (RMC/IRMAC)

This section provides instruction to the RMC/IRMAC regarding Review/Disposition of Referral Cases. When reviewing each Referral Case, you must review the following fields to ensure that they are completed and are consistent throughout the referral. Each item is addressed in detail below.

• Referral Priority (Urgent Referrals first)

• Medical Service.

• Reason for Referral

• Referral Type

• Codified Reason (Diagnosis): For referrals that will be sent to the private sector, the 278 electronic transmission allows for up to 2 diagnoses, as needed.

• Refer to Location

• Instructions to Staff (See Training Point below for details regarding this field)

• Order Comments (Cannot be modified by the RMC)

• Comments Tab

• Documents Tab

• Insurance (must select the appropriate insurance before dispositioning).

Select the “New Referrals to be Dispositioned” worklist.

1. Click Start Referral

2. Check the priority column for urgent referrals to review first.

3. Click to the right or below the patient’s name to open case details.

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4. Navigate to the insurance tab and associate the correct insurance for the case.

5. Navigate to the summary tab and select Edit on the far right of the to see the fields that can be modified by the RMC. Review the referral reason and the order comments fields to determine if all information is included. Note the order comment field cannot be modified.

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6. Review the referral type to ensure it matches the medical service and referral reason.

If the primary diagnosis does not match the reason for referral, the referral must be cancelled, and the referring provider notified of the mismatch. The referring provider must enter a new referral with the correct diagnosis.

**Warning: technically, the RMC can edit the Diagnosis Code, but DO NOT change the diagnosis. 1) This is a medical decision by the provider, 2) only the diagnoses on the order will transmit to the MCSC.

7. After reviewing and verifying that all fields are accurate, begin the next steps for dispositioning the Referral Case to the MTF, Deferring to the MCSC or Printing for OHI.

If during your review of the referral case, it is determined additional information is needed or clarification is required this needs to be accomplished BEFORE the case is dispositioned to the MTF or to the MCSC. If additional information cannot be located within the referral, or if you find a clinical discrepancy, you will have to reach out to the referring provider through message center.

8. If the information is not included, use the “Substatus” to select “Additional Information Needed” and select “Submit.”

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Appointing (Accepting) Referral to the MTF

1. Select the “New Referrals to be Dispositioned” worklist.

CHECK THE PRIORITY COLUMN FOR URGENT REFERRALS to review first.

2. Click on the open space in the “Patient” column to open case details (to the right of the name or directly below the DOB)

3. Click on Start Referral

4. Click on the insurance tab, highlight the correct health plan for the case and select Associate

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5. From the right side of the Summary tab, click “Edit.”

6. Click the magnifying glass next to the “Refer to Provider” field – OR – enter the DMIS into the

Refer to Provider and hit enter

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7. Ensure “Qualifiers:” reflects the correct Medical Service/Specialty

8. Enter the refer to DMIS in the Search field and in the “Search by:” field, change default from

“Provider” to “Practice (only need to do this the first time)

9. Select MTF, Clinic by selecting the hyperlink 1 Provider Available of the clinic you want the patient to be scheduled and click Accept. MTF, Clinic MUST BE SELETED

10. Select “Save.”

11. Enter any additional information in the “Comments” tab. For example, scheduling instructions to the clinic scheduling staff.

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12. Click the “Generate” button.

13. Review the summary that pops up and click “Send.”

14. Click Accept

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15. If sending to clinical staff to be reviewed, close the referral case using the “X” in the upper-right corner. The referral will now be in Pending Acceptance Status and will display on the clinic worklist.

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Defer Referrals to the Private Sector/Network (MCSC)

Click on the open space in the “Patient” column to open case details (to the right of the name or directly below the DOB).

2. Click on Start Referral

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3. Click on the insurance tab, highlight the correct health plan for the case and select Associate

4. Click on the Summary Tab and select “Edit” from the right side. This allows for editing of the referral case.

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5. Click the magnifying glass next to the “Refer to Provider” field.

6. Delete the Medical Specialty the Qualifiers

7. Enter “Defer” in Search

8. Check the box “Include External Practices.”

9. Click the Search button

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Four choices appear:

• Defer to MCSC electronically, DoD (triggers a 278 sent to the MCSC): This will electronically send the referral to the Managed Care Support Contractor

• Defer to MCSC via Manual/eFax, DoD (triggers printing) This will be used when the electronic 278 is not transmitting or the insurance cannot be updated.

• Defer to Non-MHS GENESIS MTF, DoD (triggers printing): This is used to send a case to an MTF on the legacy system.

• Defer to Print to Manual/eFax, DoD (triggers printing); This is used for all defer to network cases that will not be sent to the managed care support contractor. Examples include Medicare/OHI and No Authorization Required (NAR)

10. Select the blue hyperlink 10 Providers Available associated to the referral case:

11. Select the deferred reason from the below options:

• 2nd Opinion

• CB: MTF Capability

• CC: Continuity of Care

• CMD: Command Directed

• CP: MTF Capacity

• DS: Distance exceeds ATC stds

• LOD: Line of Duty

• NAR: No pre-authorization required

• OHI: Other Health Insurance

• POS: Point of Service DO NOT USE FOR ELECTRONIC TRANSMSSION – PROVIDE A

COPY OF THE REFERRAL TO THE PATIENT.

12. Click Accept

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The refer to provider will now display the referral deferral reason and the refer to location will reflect the method of deferral.

13. Click Save

14. Click Generate

The referral will update to sent/received for those going to the MCSC. All other referrals will update to the status of sent OHI Referral Processing

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CHECK THE PRIORITY COLUMN FOR URGENT REFERRALS to review first.

Click on the open space in the “Patient” column to open case details (to the right of the name or directly below the DOB).

2. Click on Start Referral

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3. Click on the insurance tab, highlight the correct health plan for the case and select Associate

4. Click on the Summary Tab and select “Edit” from the right side. This allows for editing of the referral case.

5. Click the magnifying glass next to the “Refer to Provider” field.

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6. Delete the Medical Specialty the Qualifiers

7. Enter “Defer” in Search

8. Check the box “Include External Practices.”

9. Click the Search button

Four choices appear:

• Defer to MCSC electronically, DoD (triggers a 278 sent to the MCSC): This will

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• Defer to MCSC via Manual/eFax, DoD (triggers printing) This will be used when the electronic 278 is not transmitting or the insurance cannot be updated.

• Defer to Non-MHS GENESIS MTF, DoD (triggers printing): This is used to send a case to an MTF on the legacy system.

• Defer to Print to Manual/eFax, DoD (triggers printing); This is used for all defer to network cases that will not be sent to the managed care support contractor. Examples include Medicare/OHI and No Authorization Required (NAR)

10. Select the blue hyperlink 10 Providers Available associated to the referral case:

11. Select the deferred reason from the below options:

• OHI: Other Health Insurance

12. Click Accept

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The refer to provider will now display the referral deferral reason and the refer to location will reflect the method of deferral.

13. Click Save

14. Click Generate

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The referral will update to sent

Defer to Print to Manual/eFax, DoD (triggers printing); This is used for all defer to network cases that will not be sent to the managed care support contractor. Examples include Medicare/OHI and No Authorization Required (NAR)

The letter will now populate to either be mailed or sent via message center to the patient.

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Referrals Requiring More Information

RMC/IRMAC staff may require additional information prior to the referral being dispositioned. This is the case for those staff the review referral guidelines and accept the referral according to guidelines.

Referrals requiring more information prior to disposition will be put in a status of Prepare Send/ Additional Information Needed

Click on the comments tab and document required information and click save.

Send a message to the provider and patient through Message Center (see section on Message Center)

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MTF to MTF Referral Processing

Sending MTF: After coordinating with the Receiving MHSG RMC, select the Receiving MTF RM Practice Location. For example, 7379 DHA San Antonio Market Referral Management Center.

1. In the search field enter “Referral” and click Search.

2. Select the blue hyperlink and MTF, Clinic associated to the DMIS the referral for the referral to be routed

3. The referral will now be reflected on the “MTF to MTF Referrals to be Dispositioned” worklist of the MTF being referred to.

Receiving MTF: From the MTF-to-MTF worklist either accept or reject with the reasons on the comment tab or forward to the clinic for disposition.

MTF Referrals Requiring Closure and Reorder

Training Point - This workflow is intended for the referral to be sent to another MTF using MHSG. Providers or provider care team must Coordinate care with receiving MTF before sending. If the receiving MTF is not able to accept the referral, they will send it back to the originating MTF by selecting Reject in addition to a Reason for Rejecting. That allows the originating site to determine next actions (e.g., send to other MTF or to the private sector care). This will also allow the referral to be tracked at the originating site until closure.

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If the referral has the incorrect diagnosis or the information in the order comments is incorrect the referral will need to be re-written. If this is the case, follow the following:

Referrals that need to be re-written will be Closed with a sub-status of DOD-Administrative. The comment tab must contain the reason for closing the referral.

IMPORTANT! Send a message to the ordering provider indicating the reason for the cancellation (See Message Center)

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Scheduling Initial Referral

New Appointment: Referral appointments must be scheduled from the Referral Management Worklist.

1. IN REVENUE CYCLE Go to Appoint to MTF Referrals worklist. Worklist will have

ACCEPTED referrals only.

2. Click the area near a patient’s name to view the Referral Case window; if the Patient’s Name is clicked that will open the patient’s chart.

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3. Navigate to the Scheduling tab on the RM Worklist and click the New Appointment button

4. Add Appointment Plus opens. Select the appointment type and click Next in the bottom right-hand corner.

5. Select appropriate insurance based on the patient’s profile

6. Enter relevant appointment information and identify the patient’s Primary Care Manager (PCM) and/or the referring provider in the Comment section. This comment will be visible on the Ambulatory Organizer Since providers do not have access to the Referral Management MPage, staff should take the time to include this information during the scheduling process because it will help providers know where to look to find out which PCM and/or Referring Provider referred the patient. This will help the Specialty Clinic Provider know who to add as a recipient when it comes time to the complete visit documentation.

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7. Reason for Visit will auto-populate from the referral

8. Return to the RM Worklist after scheduling the appointment and verify the appointment was associated to the referral After scheduling the referral appointment, the patient’s referral status will change from Accepted to Scheduled. The appointment should now appear on the Scheduling tab under the Associated Appointments section.

Note: Scheduling the appointment through the scheduling tab of the referral case is integral to maintaining the association to the referral

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Section 3: Processing Rejected Referrals

Rejected MTF Referral (IRMAC/RMC ONLY FUNCTION)

If the clinic rejects the referral and it is determined it needs to be sent to the MCSC.

When a specialty clinic rejects a referral, it will appear on the “Rejected Referrals” worklist.

If the referral will be sent to the MCSC it must be put in defer to MSCS status.

Put the referral in Prepare Send status.

Follow the Defer Referrals to the Private Sector/Network (MCSC) process.

Convert Accepted Referral to Defer to Network

If the clinic determines they can not provide care for a previously accepted referral

1. Change the status from Accepted to Rejected Follow the Defer Referrals to the Private Sector/Network (MCSC) process.

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MCSC Rejected Referrals

WORKLIST: MTF REJECTED BY MCSC This section explains how to address rejected referrals from the MCSC. Be sure to check the “Rejected Referrals” worklist frequently throughout the day.

Depending on the reason for the Rejected referral:

The IRMAC/RMC may be required to Message the Referring Providers and advise them the referral was closed or denied by MCSC with the reason why.

• The IRMAC/RMC will be able to correct or provide the needed information and resubmit the same referral to the MCSC.

• The IRMAC/RMC cannot correct the referral and will have to Message the Referring Provider to rewrite the referral.

Rejected by the MCSC/Referral Can Not be Resubmitted via MHSG

If the reason for rejection is “Cancelled,” follow these steps.

1. LEAVE referral in Rejected status and update substatus to Cancelled or Denied

2. Send a message to the ordering provider with the reason for the referral rejection (the information to the referring provider that the MCSC provided on the “Comment” tab)

3. Annotate the message was sent on the comment tab

Rejected by the MCSC/Referral is resubmitted via MHSG.

Follow these steps if the referral requires correction and resubmission to the MCSC for processing. If the MCSC rejects the referral and you provide the additional information/corrections to the MCSC

1. Check the Comment tab to review the reason the referral was rejected. If corrections need to be researched update the status to Rejected/DoD – Additional Information Needed

2. Once corrections are known; Change the “Status” to “Prepare Send.”

3. Make the appropriate changes using the “Instructions to Staff” fields. Use only the “Reason for

4. Referral” field if more characters are needed.

5. Ensure “Refer to Location” is accurate. In the “Insurance” tab, select appropriate TRICARE option. Click on “Save.”

6. Click on “Generate” to resubmit referral to the MCSC.

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SEND/FAILURE

“SEND_FAILURE” also appear on the Rejected Worklist.

1. Check “Insurance” tab – Make sure the correct health plan is selected. Health Plan is TRICARE Prime.

2. Make sure the medical specialty is one that can be deferred to the MCSC

3. If neither of those work to send the referral; manually fax to the MCSC and enter a ticket with the Global Service Desk

Section 4: DOD/VA Sharing Agreement Referral Request

Several MTF’s have DoD/VA Sharing Agreements which require a referral to be entered in MHSG. This section goes over the process.

1. Create an IBE through the Message center

2. Navigate to Message Center in Power Chart.

3. Expand the Communicate list.

4. Select Message.

5. Click in the Patient box.

6. Enter the patient’s name

7. Click the Search button (binoculars icon)

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8. Select the patient’s name DO NOT SELECT AN ENCOUNTER

9. Click OK.

10. Click Launch Orders, from the upper-right corner of the message window.

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11. The Location will be the referral department at the MTF, which is where the referral request was received. This location will be formatted as DMISA-REFERRAL, beginning with the specific four-digit DMIS ID number of the correct MTF location.

12. Click +Add

13. Expand the Type list.

14. Select In Office/Clinic Orders

15. Click in the Search box.

16. Enter Referral.

17. Select Referral Request 2.0

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18. Select Order

19. Enter the ordering physician – UNAVAILABLE PHYSICIAN

20. Select Written (Paper)/Fax for Communication Type

21. Click OK

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22. Click Done.

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Complete Referral Order Details

1. Select appropriate box associated with Urgent: Only use the Urgent indicator if the Referral is truly urgent

2. Expand the Medical Service list.

3. Select appropriate medical specialty.

4. Click in the Referral Reason box. Enter Referral Reason: “DoD/VA Sharing” + issue being referred, “i.e., high blood pressure”. When entering text into the referral reason box: Entries must contain more than five characters, no special characters are allowed, and copy/paste is not allowed.

5. Expand the Referral Order Type list and select Evaluate and Treat.

6. Confirm No is selected in the ROFR box. (This is a VA referral)

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7. Click the Order Comments tab and add the requesting provider, requesting location, fax number, and any other details about the requester or referral order. Order comments cannot be modified after the order is signed.

8. Click the Diagnosis tab.

9. Click in the search box and enter the Referral Diagnosis.

10. Select appropriate diagnosis

11. Carefully review information before you click Sign. Once you click Sign, the order will be placed. All changes after this point must be done within the Referral Management MPage view. If the referral was ordered incorrectly, it must be closed from the Referral Management Worklist or Patient Centric Search view.

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12. Click Sign.

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Accept VA/DOD Referral

2. Click on the open space in the “Patient” column to open case details (to the right of the name or directly below the DOB)

3. Click on Start Referral

4. Click on the insurance tab, highlight the correct health plan for the case and select Associate Select the DOD-VA Sharing profile and associate the appropriate DoD/VA Sharing Agreement Health Plan. (Local, Alaska, or Joint Incentive Fund (JIF)).

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The following health plans are the only plans to be used with DoD/VA sharing and must be manually entered if not already entered during registration. Verify if the MTF has a DoD/VA sharing agreement. If they do, select the appropriate tab from the below options.

DoD/VA Sharing Agreement Health Plan options:

DoD VA Sharing Agreement NATIONAL: This plan only covers encounters such as Integrated Disability Evaluation System (IDES) or Multi-Trauma and has either a set negotiated rate or a Tricare rate less 20%. (Note: At this time, DoD will not utilize this health plan.)

DoD VA Sharing Agreement LOCAL: This plan will be used when a specific MTF and VAMC have an approved agreement and is negotiated at the TRICARE rate less 20%.

DoD VA Sharing Agreement ALASKA: This plan will be used for any MTF/VAMC that is in Alaska and is negotiated at the TRICARE rate less 10%.

DoD VA Sharing Agreement Joint Incentive Fund (JIF): This plan is only used if there is an active JIF for that facility with no billing occurring between the agencies.

If the DoD/VA Sharing Agreement Health Plan is not available for selection, follow the ‘1DOD – Registration – Manage Person and Health Plan Updates’ workflow to manually add the Health Plan with a Begin Effective Date of the date the patient is approved for services.

5. Click Associate

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6. IMPORTANT STEPS On the Insurance Tab: Enter the:

• VA Authorization Number in the Insurance Tab (found in referral packet). The referral case must be in a Prepare Send, or Pending Acceptance status to add the authorization number in the Insurance tab. The Refer to location must also be chosen to be able to add the authorization manually.

• Enter Authorization in Authorization Type.

• Enter Approved in Authorization Status.

7. From the right side of the Summary tab, click “Edit.”

8. Click the magnifying glass next to the “Refer to Provider” field – OR – enter the DMIS into the

Refer to Provider and hit enter

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9. Ensure “Qualifiers:” reflects the correct Medical Service/Specialty

10. Enter the refer to DMIS in the Search field and in the “Search by:” field, change default from

“Provider” to “Practice (only need to do this the first time)

11. Select MTF, Clinic by selecting the hyperlink 1 Provider Available of the clinic you want the patient to be scheduled and click Accept. MTF, Clinic MUST BE SELETED

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10. Select “Save.”

11. Enter any additional information in the “Comments” tab. For example, scheduling instructions to the clinic scheduling staff.

12. Click the “Generate” button.

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13. Review the summary that pops up and click “Send.”

14. Click Accept

15. If sending to clinical staff to be reviewed, close the referral case using the “X” in the upper-right corner. The referral will now be in Pending Acceptance Status and will display on the clinic worklist.

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VA/DOD Referral Upload Referral Packet

Scan the referral packet in RM 2.0. The referral packet includes the HSRM authorization (also known as the Referral Number), Standard Episode of Care (SEOC), and clinical documentation.

1. Go to the patient’s chart from the Referral Management worklist by clicking on the patient’s name.

2. Assign relationship to the patient (if not previously performed).

3. Select Patient from the Task Bar.

4. Select View Images from the drop down.

5. In the Document Image window select the Scan/Import new image icon.

6. Navigate to Image Type, select specialty consultation from dropdown.

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7. Enter the date the referral packet is sent in the Date Field.

8. Select A Parent: The system will automatically default to the FIN from the referral case.

9. Select the appropriate Scan or Import button based on local protocols.

10. Author: End user uploading the document (as the system is designed).

11. Patient Level Document: Leave this box unchecked.

12. Click Sign to finalize and upload the document.

13. Associate uploaded documents to referral

14. Click on the Referral Management tab (top toolbar of PowerChart) to go back to the referral case. Re-Open the referral details, if needed.

15. Go to Documents tab.

16. Highlight the document (VA SEOC Packet - <Specialty>) that you just uploaded under

Available Documents.

17. Click Add. It will now show in Attached Documents

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Section 5: Right of First Refusal (ROFR) Referrals

WILL BE UPDATED IN NOVEMBER 2023

Accept A ROFR

This section provides instructions for how to process ROFRs received from the Managed Care Support Contractor (MCSC). If the patient needs to be registered in MHSG to create the ROFR order, contact Patient Administration.

• Retrieve the ROFR request from the MCSC Portal.

• Review the ROFR Request against the MTF Capability/Capacity Report

• Check if specialty is consistent with requested reason for referral.

• Check drive time (against Access to Care Standard)

• Check for Continuity of Care requirements.

• If the ROFR cannot be accepted, enter response in the MCSC Portal. Be sure to include reason for not accepting (i.e., MTF Capacity, Distance exceeds ATC standard, etc.).

• If the ROFR is accepted, continue with process below.

1. Create an IBE through the Message center

2. Navigate to Message Center in Power Chart.

3. Expand the Communicate list. Select Message

5. Click in the Patient box.

6. Enter the patient’s name

7. Click the Search button (binoculars icon)

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8. Select the patient’s name DO NOT SELECT AN ENCOUNTER

9. Click OK.

10. Click Launch Orders, from the upper-right corner of the message window.

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11. The Location will be the referral department at the MTF, which is where the referral request was received. This location will be formatted as DMISA-REFERRAL, beginning with the specific four-digit DMIS ID number of the correct MTF location.

12. Click +Add

13. Expand the Type list.

14. Select In Office/Clinic Orders

15. Click in the Search box.

16. Enter Referral.

17. Select Referral Request 2.0

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18. Select Order

19. Enter the ordering physician – UNAVAILABLE PHYSICIAN

20. Select Written (Paper)/Fax for Communication Type

21. Click OK

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22. Click Done.

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Complete Referral Order Details

1. Select appropriate box associated with Urgent: Only use the Urgent indicator if the Referral is truly urgent

2. Expand the Medical Service list.

3. Select appropriate medical specialty.

4. Click in the Referral Reason box. Enter Referral Reason: “ROFR” + issue being referred, “i.e., high blood pressure”. When entering text into the referral reason box: Entries must contain more than five characters, no special characters are allowed, and copy/paste is not allowed.

5. Expand the Referral Order Type list and select Evaluate and Treat.

6. Confirm Yes is selected in the ROFR box. (This is a VA referral)

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7. Click the Order Comments tab and add the requesting provider, requesting location, fax number, and any other details about the requester or referral order. Order comments cannot be modified after the order is signed.

8. Click the Diagnosis tab.

9. Click in the search box and enter the Referral Diagnosis.

10. Select appropriate diagnosis

11. Carefully review information before you click Sign. Once you click Sign, the order will be placed. All changes after this point must be done within the Referral Management MPage view. If the referral was ordered incorrectly, it must be closed from the Referral Management Worklist or Patient Centric Search view.

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12. Click Sign.

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Reject a Previously Accepted ROFR Referral

There are occasions when an MTF will accept a ROFR and it is later determined the care cannot be provided at the MTF. This section will cover that process.

From the rejected worklist update the status of the referral to CLOSED/ROFR DECLINED Add appropriate comments to the comment tab – why is the referral moving from accepted to declined status.

Update the Managed Care Support Contractor Portal

Right of First Refusal (ROFR) Referral Results:

Provide MTF results to civilian referring providers for ROFRs seen at the MTF within 10 business days of kept appointment. Close the referral with a status of “Closed” and a substatus of “Results Sent” Note in the Comments Tab of the referral case the date the ROFR results were sent to the civilian provider.

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Section 6: Clinic Review/Clinic Book/ De-Centralized Worklists

Pending Acceptance Referrals Use this worklist to view all referrals sitting in a MTF specialty clinic worklist, waiting to be Accepted or Rejected. Per DHA policy, MTFs have one business day to disposition a referral (Accepted or Defer to Network). RMCs must monitor in clinic worklists and disposition per policy.

Appoint to MTF Referrals Use this worklist to view all referrals ready for booking the initial specialty care appointments in the MTF/Market. If you used a Centralized type of worklist in the New Referrals to Be Dispositioned worklist above, you do not need this worklist.

Close the Loop Use the worklist to track referrals written by the specialty provider to close once CLR has been received.

SPECIALTY CLINIC WORKLISTS

Worklist Name Type and Filters (no selection defaults to all) lin ic R ev ie w

Clinic Specialty Pending Acceptance Referrals

Type: Receiving

*Refer to Location: Select MTF Clinic location Refer to Provider: System defaults to all Medical Service: System defaults to all Status: Pending Acceptance Priority: System defaults to all Referral Type: System defaults to all Refer from Provider: System defaults to all Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

C lin ic B oo k/

A pp oi nt

Appoint to MTF

*Refer to Location: Select MTF locations

Medical Service: System defaults to all Status: Accepted; Pending Reschedule; On-Hold Priority: System defaults to all Referral Type: System defaults to all Refer from Provider: System defaults to all Dates: Select as needed; system defaults to all Assignment: No selection: system defaults to all

C lin ic /C lo se th e

Lo op

Close the Loop

Refer From Location: Select all MTF locations Refer From Provider: Select Clinic Providers Medical Service: System defaults to all Status: Patient Seen; Closed/Results Received Pending Review Priority: System defaults to all Referral Type: System defaults to all Refer to Location: System defaults to all Refer to Provider: System defaults to all

Assignment: No selection

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Clinic Referral Review Process (De-Centralized)

Section Overview: This section describes how the specialty clinic staff review and disposition a referral case once the RMC staff has started the referral case process and has “sent” it to the specialty clinic. Per DHA policy, the review of referrals at the specialty clinic requires written waiver by the MTF Commander/Director and should be the exception.

Decisions: Specialty clinic reviewers will have to make one of the following decisions (dispositions):

• Accept the referral case for appointing in the clinic.

• Reject the referral case (reason required) for the RMC to send to the MCSC or another

MTF.

1. In Power Chart, go to the Referral Management MPage by clicking on the “Referral

Management” button in the toolbar or clicking “View” and select “Referral Management.”

2. Select the New Referrals to Be Dispositioned Clinic Specialty worklist.

3. Review and Disposition the Referral Cases, URGENT referrals first.

4. Note the “Status” on the referral case is “Pending Acceptance.” From the “Summary” tab, review the case details and make disposition decision (Accept, Reject).

5. Accept Referral Case by selecting the “Accept” button.

6. Enter any booking instructions on the comment tab.

7. Close by selecting the x in the upper right-hand corner of the case.

Training Point: To save specialty clinic staff administrative time, the RMC should review referral cases in the “Not Started” status based on the MTF/specialty clinic standard referral guidelines (SRG). The specialty clinic would only review referral cases in the “Pending Acceptance” status when there are questions on whether to “Accept” the referral (book in specialty clinic) or “Reject” the referral (defer to network).

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1. Reject Referral Case by selecting the “Reject” button.

2. Select reason for rejection. Don’t use the “Comments” field in the pop-up box. Please put comments in the “Comments” Tab of the referral case. Comments in the pop-up disappear when the status is changed and there will be no record of your comments.

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3. Enter the rejection reason on the comment tab. Only comments in the “Comments” Tab are recorded.

4. Close the Referral Case using the “X” in the upper-right corner. Referral case will change to

“Rejected” with the reason for rejection displayed and flow to the “Rejected Referrals” worklist for the RMC to send to the appropriate external location (i.e., defer to the network, send to another MTF, etc.).

DO NOT CHANGE the Refer to Location. The RMC will determine where to send the referral.

Simply “Reject” the referral.

Refresh worklist.

O…