This document provides guidance for a referral specialist at Mount Vernon Internal Medicine. It discusses daily duties such as submitting insurance referrals and authorization requests. It reviews the referral processes and forms for major insurances like Tricare, CareFirst, UnitedHealthcare, and Aetna. It also discusses following up on referrals and notes, as well as authorizing radiology services. The overall goal is to help patients understand insurance benefits and receive full value from medical services through efficient referral management.

1. ~ 1 ~
TABLE OF CONTENTS
Page 3 Daily Duties of a ReferralSpecialist
Page 4 Types of Insurances That Require Referrals
Page 6 Tricare ReferralForm
Page 8 CarefirstReferralForm
Page 10 United Healthcare Optimum Choice ReferralForm
Page 12 Aetna/ Innovation Health Online ReferralForm
Page 17 RadiologyCenters
Page 21 RadiologyPriorAuthorization Walk Through
Page 22 Attaching SpecialistProgress Notes/RadiologyReports to Chart

2. ~ 2 ~
Standing Operating Procedure
Referral Specialist for Mount Vernon Internal Medicine
Missionstatement:
At Mount Vernon Internal Medicine, we pledge to help our patients and employees to understand the
value of good health. Our goal is to provide patient care through a strong physician/patient relationship to
ensure full benefits from our services. We will maintain a professional, friendly, and cheerful attitude.
Patient care is done with state of the art technology and old fashion concern.
INTRODUCTION:
Referral Specialists report to their office manager and take direction from Office managers and providers.
You must be proficient in typing, spelling and grammar. Have strong organizational skills, and be very
detail oriented. You must have knowledge of basic medical terminology, and be able to work independently.
You must be professional courteous and motivated. You must be able to communicate effectively in writing
and over the phone.
Purpose:
The purpose of this SOP is to provide guidance and consistency throughout the jobs and responsibilities of a
medical assistant with Mount Vernon Internal Medicine. This SOP will provide overall procedures for each
unit and references for all employees within Mount Vernon Internal medicine. This SOP is designed to work
with continuous adaptations of the workflow process and to ensure quality customer service.

3. ~ 3 ~
Daily Duties and responsibilities of a Referral Specialist:
 Writing or submitting referrals for the appropriate insurance company
 Understanding the different policies and procedures of each insurance company
 Checking faxes and printing/ mailing Tricare referral approval letters.
 Calling the insurance company to get authorization for procedures such as CT scans and MRI’s.
 Checking voicemail and email for referral requests
 Keeping track of all referrals given by the Medical Providers via Clinical Module.
 Following up on pending referrals so that they are processed in a timely manner
 Acting as Liaison between patient and Medical Provider to ensure referrals are done correctly and
update if need be.
 Sending orders to the appropriate Home Health agency- Demographic sheet and Home Health order
 Sending DME supply orders to the appropriate DME company- Demographic sheet and DME order.
 Following up on past referrals to make sure patients are able to schedule their specialist appointments
 Following up on past radiology orders to make sure the patient was able to schedule without problems.
 Following up on consultation notes from specialists and radiology reports.

4. ~ 4 ~
Types of Insurances That Require Referrals:
Each insurance has its own guidelines to follow:
AETNA:
AETNA PPO: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED REFERRAL)
RADIOLOGY: MAY GO TO ANY IN-NETWORK RADIOLOGY FACILITY
AETNA OPEN ACCESS: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED
REFERRAL)
RADIOLOGY: MAY GO TO ANY IN-NETWORK RADIOLOGY FACILITY
AETNA HMO: REFERRALS MUST BE SUBMITTED VIA NAVINET (SPECIALTY AND RADIOLOGY)
ANTHEM:
ANTHEM PPO: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED REFERRAL)
ANTHEM HEALTHKEEPERS PLUS: REFERRALS NOT REQUIRED FOR IN-NETWORK
SPECIALISTS
* MANY SPECIALISTS DO NOT ACCEPT THIS INSURANCE
RADIOLOGY: MAY GO TO FREE STANDING RADIOLOGY FACILITIES: EX. (DRAD)
(AAR)
ANTHEM HEALTHKEEPERS HMO: SPECIALTY AND RADIOLOGY REFERRALS REQUIRED
* MANY SPECIALISTS DO NOT ACCEPT THIS INSURANCE
CAREFIRST BCBS:
CAREFIRST PPO: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED REFERRAL)
RADIOLOGY: MAY GO TO ANY IN-NETWORK RADIOLOGY FACILITY
CAREFIRST BLUECHOICE OPEN ACCESS NO INSURANCE REFERRALS REQUIRED (JUST TAKE
PRINTED REFERRAL)
RADIOLOGY: MAY GO TO FREE STANDING FACILITIES
HOSPITALS ARE NOT RECCOMMENDED/ USUALLY NOT COVERED
CAREFIRST BLUECHOICE HMO: WRITTEN REFERRALS REQUIRED (ALL SPECIALTY AND
RADIOLOGY)
RADIOLOGY: MUST GO TO FREE STANDING FACILITIES
HOSPITALS ARE NOT RECCOMMENDED/ USUALLY NOT COVERED

5. ~ 5 ~
MEDICAID:
STRAIGHT MEDICAID OF VA: REFERRALS NOT REQUIRED FOR SPECIALISTS AND
RADIOLOGY
* MANY SPECIALISTS DO NOT ACCEPT THIS INSURANCE
IN TOTAL HEALTH: REFERRALS NOT REQUIRED FOR IN-NETWORK PROVIDERS
* MANY SPECIALISTS DO NOT ACCEPT THIS INSURANCE
MEDICARE:
SPECIALSTS: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED REFERRAL)
RADIOLOGY: NOT AUTHORIZATION REQUIRED. MAY GO TO ANY RADIOLOGY
FACILITY
TRICARE:
ALL TRICARE RADIOLOGY (EXCEPT DEXAS): NO AUTHORIZATION NEEDED
MAY GO TO ANY IN-NETWORK RADIOLOGY FACILITY
DEXAS SHOULD BE SUBMITTED DUE TO AGE REQUIREMENTS
TRICARE FOR LIFE: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED REFERRAL)
TRICARE STANDARD: NO INSURANCE REFERRALS REQUIRED (JUST TAKE PRINTED
REFERRAL)
TRICARE PRIME: ALL SPECIALTY REFERRALS NEED SUBMITTED
I have attached copies of each referral form explaining how to fill out. I have also attached screen shots of
how to submit online. These go in order of popularity. Tricare and Carefirst are the most common forms you
will fill out almost on a daily basis.

6. ~ 6 ~
Tricare Referral Form:
This form is labeled HEALTH NET FEDERAL SERVICES TRICARE SERVCICE REQUEST/NOTIFICATIONFORM
and copies will be in the BLUE Tricare folder.
Tricare has two options of approval time.
1- “Within 72 hours”- means this is an URGENT referraland the patient should be seen within 72 hours. If the referral
is STAT please write “EMERGENT” on top of the form.
2- “Outside 72 hours”- means this is not urgent and can be processed after 72 hours
For “Service Type” please make sure to mark off “Specialist Referral”,Physical Therapy”, “OP Behavioral Health”,etc.
On the right hand side there is “Requesting Provider Information”
- please write the Medical Provider’s name and fill in the Requesting provider’s NPI.
Verify if this is a new referralor a renewaland place a check mark in box
Under “Patient Information”
Enter in the Sponsor’s SSN. This may not necessarily be the patient’s SSN.
Write the Patient Name:
2- DOB
3- Patient Address
4- Zip Code
5- Patient Home Phone
Next is Servicing Provider information

7. ~ 7 ~
“Servicing ProviderInformation”
1. Specialty
2. Servicing Provider Name or Facility Name
3. Address, Phone and Fax Number
Next fill in:
1- Diagnosis ICD-9 code. This can be found on the referralyou were given or in the chart
2- CPT code. This will be 99211 for “eval and treat” – rarely you will have to use another code. Usually done for
Echos which is 93306
3- Number of Visits the patient always gets 6
*note if this is for Physical therapy please write in the description section “Physical Therapy Eval & treat”. When
submitted Tricare will automatically put the correct multiple codes
Same with Psychology- write “OP Behavioral Health Eval and Treat”.

8. ~ 8 ~
CARFIRST REFERRAL FORM
Use the Uniform Consultation ReferralForm located in the YELLOW Carefirst folder
Fill in
1- Date of Referral
2- Name of patient
3- DOB
4- Patients Phone Number
5- Insurance ID of the patient- can be found in allscripts
Primary or Requesting Provider
1- Name of Medical provider that is referring
2- Use the stamp for Institution/ Group Name and Address
3- Add phone number and fax number
Consultant/ Facility Provider
1- Specialty
2- Name or group name
3- Address
4- Phone and Fax number

9. ~ 9 ~
ReferralInformation
1- Reason for referral- always put Eval & treat,you can add follow up or PT eval & treat
2- Brief History, dx, and test results- usually just put the dx code here or write out the diagnosis
- If the dx is very personal I only put the code.
Place of Service- office or Radiology
Number of visits- 1 for procedures, 3 for office visits, 12 for Physical therapy
Referralvalid- 4 months from date of referral
Signature- sign off

10. ~ 10 ~
UNITED HEALTHCARE OPTIMUM CHOICE REFERRAL FORM
Please use the Primary Care Physician Referralin the RED folder
Section 1.- Member identification, our provider’s information and the information of the provider
we are referring to

11. ~ 11 ~
Section 3- This is where you will write the diagnosis code and any pertinent information
Section 4- Please check off Consultation ad treatment and add 6 visits
Have provider sign off
If the patient has an appointment with the specialist you may fax this form over or give directly to the patient.

12. ~ 12 ~
AETNA or INNOVATION HEALTH
RERFERRAL (SUBMIT ONLINE VIA NAVINET)
Log into NAVINET
Click Aetna/ INNOVATION HEALTH (Branch off from Aetna- look on ID card) under workflows
-Both companies are set up exactly the same just with different names-
Click Referrals and click referralsubmission

13. ~ 13 ~
Change the requesting provider to Dr Albert Herrera
Type in Member ID, Member DOB and Member’s Last Name
Click Search

14. ~ 14 ~
Once new screen pops up
Step 1.Click provider search and search for the provider we are referring to
Step 2. Change number of visits to 6 for Eval and Treat keep place of service as OFFICE
- If it is for a procedure change place of service to OP Hospital and keep as 1 visit

15. ~ 15 ~
Step 3. Enter diagnosis code of the reason why we are referring them out
Step 4. Enter the Procedure code.
99499- Eval and Treat
Or use the procedure code if the referralis only for a procedure.
Click submit
Lastly, print out 2 copies of the referralthat is approved. A “ReferralResponse” will pop up print this page and then hit
“View Referral/ Auth” then print this page also. Print out the current page once it loads and also the following page.
Examples are shown on the following two pages.
This referralis valid for a year and has already been submitted to the insurance company.
Index 1 copy into chart and send the patient the other copy.

16. ~ 16 ~
RADIOLOGY CENTERS:

17. ~ 17 ~
It is recommended by most insurances that patients use “Free Standing Facilities”. These facilities are cheaper
when compared to the hospital service charges. Most of these “Free Standing Facilities” participate with the insurance we
work with.
If a Medicare or Tricare patient requests to use the hospital affiliated facilities this is OK. There have not been any
complaints from patients that use these facilities who have either of these insurances.
I have attached on page 18 & 19 both “Radiology Center” print outs that I have typed up to easily hand to patients.
On page 20 is Aetna’s Preferred Radiology Center list.

18. ~ 18 ~
Radiology Centers
(Free- Standing Facilities)
AAR Alexandria Imaging Center- 4660 Kenmore Ave #525 Alexandria, VA 22304
(DEXA, Mammography, Ultrasound, Vascular Ultrasound, X-Ray)
AAR Woodbridge Imaging Center- 4001 Prince William Parkway #302 Woodbridge, VA 22192
(DEXA, Mammography, Ultrasound, Vascular Ultrasound, X-Ray)
Appointment Scheduling: 703-824-3260
FRC Woodburn Diagnostic Center- 3299 Woodburn Road #110 Annandale VA 22003
(CT, Echo, Fluoroscopy, Ultrasound, X-Ray)
FRC Springfield Imaging Center- 5510 Alma Lane #100 Springfield, VA 22151
(DEXA, X-Ray, Mammography)
FRC Fairfax MRI Center- 8318 Arlington Blvd #100 Fairfax, VA 22031
(MRI, MRA)
FRC Ultrasound Center- 8503 Arlington Blvd #LL-100 Fairfax, VA 22031
(Ultrasound)
FRC Fairfax Diagnostic Imaging Center- 3801 University Drive #120 and #130 Fairfax, VA 22030
(#120- CT, Ultrasound, #130- DEXA, Mammography, X-Ray)
FRC Fairfax PET/CT Imaging Center- 8503 Arlington Blvd #120 Fairfax, VA 22031
(PET, CT)
Appointment Scheduling: 703-698-4488
Insight Imaging- Woodbridge- 4001 Prince William Pkwy #104 Woodbridge, VA
(MRI, MRA) Appointment Scheduling: 703-490-3677
Insight Imaging- Arlington- 2786 South Arlington Mill Dr. Arlington, VA
(Open MRI, MRI) Appointment Scheduling: 703-820-2775
Insight Imaging- Fairfax- 10721 Main St. #G1 Fairfax, VA
(MRI, CT, Ultrasound, Fluoroscopy, DEXA, X-Ray) Appointment Scheduling: 703-591-8020
NOVANT Health Imaging Tysons Corner- 102 Maple Ave East Suite 1-A Vienna, VA 22180
(CT, OPEN MRI, Ultrasound, X-Ray)
NOVANT Health Imaging Tysons Corner- 8320 Old Courthouse Road Tysons Corner, VA 22182
(MRI, MRA)
Appointment Scheduling: 703-356-4900
While we make every effort to know the referral and pre-authorization requirements of the insurance plans we are contracted with, it is our
recommendation that you contact your insurance company if you are unsure about whether they will cover the procedure. Even if they cover the
procedure, you will be responsible for any co-payment, co-insurance, or deductible amount specified by your insurance plan.

19. ~ 19 ~
Please check your insurance identification card for the telephone numbers to call.
Radiology Centers
(Hospitals)
Sentara Marketplace- 9455 Lorton Marketplace St. Lorton, VA
(CT, Ultrasound, X-Ray)
Sentara Lorton Station Women’s Imaging Center- 8986 Lorton Station Blvd. #200 Lorton, VA
(Ultrasound, Mammography, DEXA)
Sentara Springfield Imaging- 6128 Brandon Ave. #205 Springfield, VA
(CT, Mammography, Ultrasound, X-ray, DEXA)
Sentara Lake Ridge- 12825 Minnieville Rd. Lake Ridge, VA
(MRI, CT, 3D Mammography, Ultrasound, X-ray, DEXA)
Sentara Mt Vernon Imaging- 8109 Hinson Farm Rd. #108 Alexandria, VA
(Mammography, Ultrasound, X-Ray, DEXA)
Sentara Ultrasound Associates- 5055 Seminary Rd. #104 Alexandria, VA
(Mammography, Ultrasound, DEXA)
Sentara NOVA Medical Center- 2300 Opitz Blvd Woodbridge, VA
( MRI, CT, Mammography, Ultrasound, X-Ray, DEXA)
Appointment Scheduling: 703-523-1560
INOVA Lorton Healthplex- 9321 Sanger St. Lorton, VA
(CT, DEXA, Mammography, Ultrasound, X-Ray)
INOVA Mount Vernon Hospital- 2501 Parkers Ln, Alexandria, VA
(CT, DEXA, Mammography, Fluoroscopy, MRI, Ultrasound, X-Ray)
INOVA Franconia/Springfield Imaging Center- 6355 Walker Ln. Alexandria, VA
( CT, DEXA, Mammography, MRI, Ultrasound, X-Ray, Fluoroscopy)
INOVA Alexandria Hospital- 4320 Seminary Rd. Alexandria, VA
(CT, Ultrasound, Mammography, Fluoroscopy, MRI, PET/CT, X-ray)
Appointment Scheduling: 571-423-5400
While we make every effort to know the referral and pre-authorization requirements of the insurance plans we are contracted with, it is our
recommendation that you contact your insurance company if you are unsure about whether they will cover the procedure. Even if they cover the
procedure, you will be responsible for any co-payment, co-insurance, or deductible amount specified by your insurance plan.

20. ~ 20 ~
Please check your insurance identification card for the telephone numbers to call.
Aetna
Informatics - PCMH
Radiology Non-Preferred and Preferred Facilities
Claims Incurred 1/1/14 thru 9/30/14
Non-Preferred Preferred
InovaFairfax Hospital MRI of Reston
RestonHospital Center- HCA Affiliate WashingtonRadiologyAssociates
VirginiaHospital Center Fairfax MRI Centerat Reston
NovantHealthPrince WilliamMedical Cen LoudounImagingCenter/Ashburn,LLC
InovaFair OaksHospital Fairfax MRI and ImagingCenteratTysons
SentaraNorthernVirginiaMedical Center NovantHealthImagingTyson'sCenter
InovaMount VernonHospital InsightImaging- Fairfax
InovaLoudounHospital InsightImaging- Arlington
InovaAlexandriaHospital Associationof AlexandriaRadiology
NovantHealthHaymarketMedical Center NovantHealthImagingVienna
GeorgetownUniversityHospital RadiologyImagingAssociates@Sterling
George WashingtonUniversityHospital Fairfax PET-CTImagingCenter
SibleyMemorial Hospital U.S. Imaging
JohnsHopkinsHospital Medical Imagingof Fredericksburg
Children'sNational Medical Center UnitedRads,LLC
WashingtonHospital Center Optimal RadiologyPartnersof Virginia,
FauquierHospital Universityof VirginiaImaging,LLC
Warren Memorial Hospital RestonRadiologyConsultants
Fox Chase Cancer Center Fair OaksImagingCenter
CarilionNewRiverValleyMedical Center Associationof AlexandraRadiologists
Universityof VirginiaHealthSciencesC Petof RestonLP
WashingtonDC VAMC ArlingtonRadiologyAssociates
VCU HealthSystem Manassas Heart Center,LLC
Hospital forSpecial Surgery Drs. Groover,Christie &Merritt,P.C.
Memorial SloanKetteringCancerCenter VirginiaMRI
SRMH Medical Center
JohnsHopkinsBayviewMedical Center
Martha JeffersonHospital
WinchesterMedical Center,INC.
StaffordHospital,LLC
Thomas JeffersonUniversityHospital
ChristianaCare HealthServices
SentaraWilliamsburgRegional Medical Ce
Riverside Regional Medical Center

21. ~ 21 ~
Radiology Prior Authorization Walk Through:
When possible, it helps to send to facilities that do their own authorizations such as:
INSIGHT IMAGING, FAIRFAXRADIOLOGY or SENTARA.
This will save time so you can work on other referrals/authorizations.
To help these facilities, please make sure you fax over EVERYTHINGthat is in direct relation to the diagnosis of the
procedure. This includes:
- ALL office notes mentioning the diagnosis.
- Previous X-Rays, CT’s, Sonograms, MRI’s
- Progress notes from the Specialists that are treating the patient for this diagnosis.
If the patient goes to a place like INOVA you must do the PA yourself. There are two ways to do this. You can either
CALL or DO ONLINE. I advise calling since it is easier especially if you think the case is difficult to explain or has a low
chance of being approved. Please speak with the facility FIRST to verify you have the correct CPT code, diagnosis
on file, and correct phone# to call to do the authorization.
Calling the insurance the Prior-Authorization line:
- #1 MOST IMPORTANT-It is best to review/familiarize the chart before you call.
- Look into previous office notes to find out information on the symptoms:
Howoften? What does it feel like? What other parts ofthe body does it affect?
DID THE PROVIDER FIND ANYTHING ON THE PHYSICAL EXAM?
- These are all the types of questions the nurse will try to fire at you. This is why it is best to review chart before
- You are allowed to read off the notations documented in the chart.
- Submitting the Prior-Authorization online (you will need my login information)
The site walks you through the process. Be aware that the symptoms that the patient is experiencing are not
always an option you can pick. You’ll have to enter the information and it will go to clinical review which means
they’ll ask for you to fax over all the information.
When you call there is a higher chance ofapproval same day.
-DENIAL
In some cases the authorization is denied because the insurance company would like them to try Physical Therapy,
6weeks of physician directed treatment including anti-inflammatory/ pain meds, or they may recommend another
procedure to be ordered.
Sometimes the auth. is denied and there is no other option but a Peer to Peer. This isn’t necessarily bad, but try to avoid
it at all costs. It may happen when there just isn’t enough information in the chart. When a Peer to Peer is needed the
ordering provider must speak with one of their MD's to explain why it is a necessary procedure.
- www.medsolutionsonline.com
- IN TOTAL HEALTH,AETNA,CIGNA, COVENTRY
- www.unitedhealthcareonline.com
- www.provider.carfirst.com – (The same site we use for eligibility)

22. ~ 22 ~
- It is much easier to call for this insurance.
ATTACHING RECEIVED CONSULTATION NOTES AND RADIOLOGY REPORTS
TO THE ORDER IN THE CHART:
When you open clinical you will see documents that were sent to you from the electronic fax. These documents need to be
attached to their order in the chart and sent to the provider to review.
To do this you will need to click on the document which will bring you to the next screen
Verifythe type of documentiscorrectand click on the type againto copy itto the “Title”section.

23. ~ 23 ~
Afterverifyingthe type of documentyouwill thenattachittothe orderthat the Provideraddedtothe chart. Click the
drop downarrownextto Index andselect“Plan”
Thiswill bringyouto the nextscreen
Please findthe appropriate matchingorder.Verifythe date tomake sure itis the mostrecent.
Clickthe order.Thiswill nowtake youto the next screen.

24. ~ 24 ~
The order isnowattached to the document.Itisreadyto be forwardedtothe orderingProviderforreview.
Selectthe correctCaregiverandhitsend.Thiswill now sendthe document.Once approved,itwill gointothe chartand
attach to the order as outlinedonthe nexttwoscreens.

25. ~ 25 ~
You can nowclick the + and a dropdownwill appearwiththe attacheddocument.Thiswill allow youtodouble clickthe
documentandbringup the nextscreen.

26. ~ 26 ~