Referral Request Tip Sheet

Purpose of the Referral Request
Referral Requests are used to contact Physicians to request a referral for a given patient whose Insurance requires a referral.

Completing the Referral Request Form:

Indicate Payer (Required)
Select payer from the drop-down list.

Requesting Provider (Required)
By using the search box, you can enter information for any of the search criteria option listed including:

Payer ID (Payer assigned provider ID)
Provider Name
Tax ID
NPI
Address
City
State
Zip Code
Taxonomy

You may also want to sort providers using these same options by clicking on the corresponding arrows. Results of your search can be listed in 100 – 1,000. You may also look through pages of entries by clicking the left or right arrows.

Providers must be selected (highlighted in teal).

Servicing Provider Search (Required)
Search for the servicing provider by:

Payer ID (Payer assigned provider ID)
First Name
Last Name (full or partial)
Tax ID
NPI
Address
City
State
Zip Code
Taxonomy

Member Information (Required)

Member DOB
Member Number

Diagnosis Code Lookup (Required)
Enter the Diagnosis code, with applicable decimal or type word/phase and scroll through the drop-down list to choose a code/description. YOU MUST click the Diagnosis Code from the list, otherwise you will not be able to submit the request. You can also change the Diagnosis Code by re-entering a diagnosis code or work/phase in the field.

You must select the desired Diagnosis Code from the list prior to submitting form.

Referral Information (Required)
The following fields are required but are defaulted. If you need to change, you must do so in each of the fields:

Start Date
Duration
Service Facility

Message text may not exceed 255 characters.

If choosing Accident as Related Causes; Accident Country, Accident State, if within the US, and Accident Date must be entered.

If you do not enter the required information, the submit button will be 'greyed' out until all required elements are entered. Click on the "Info" button for required data for each section for additional information.

Helpful Hints for All Payers
Referrals to clinics must be made to individual providers, not the clinic or facility.

Payer Specific Helpful Hints

Independent Health
The eligibility response, "additional information" section, will indicate if a referral is required for a member at the product level. Requesting referrals for plans that do not require a referral will return a "No Action Required (NA)" message on the Referral Request Response page.

Univera Healthcare
Chiropractic referrals must be obtained through Palladian Health.
Open ended referrals will indicate an end date of 12/31/2199

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