Verbal or formal written document that gives approval to a managed care plan member to obtain medical services outside of the network of participating providers (e.g., primary care physician approves a plan member to see a specialist).

Telephone service staffed by nonclinical personnel that directs patients to approved hospital facilities and physicians and may also perform triage. Managed care plans use these call centers to communicate with patients and providers and sometimes to precertify or preapprove care. Usually the center has a toll-free 800 number for easy access and no charge to health plan members. Also known as call center, 24-hour certification, or triage .

Funds put aside for noncapitated medical services given by a primary care physician (PCP), referral specialist, or emergency services.

Any specialty, inpatient, outpatient, or laboratory services that are ordered or arranged but not furnished directly. Certain situations may exist that should be considered referral services for purposes of determining if a physician/group is at substantial financial risk (see Box R-1 ).Box R-1REFERRAL SERVICESExample 1: A managed care organization (MCO) may require a physician group/physician to authorize retroactive referral for emergency care received outside the MCO’s network. If the physician group/physician’s payment from the MCO can be affected by the use of emergency care such as a bonus if emergency referrals are low, then these emergency services are considered services and must be included in the calculation of substantial financial risk.Example 2: If a physician group contracts with an individual physician or another group to provide services that the initial group cannot provide itself, any services referred to the contracted physician group/physician should be considered referral services.

Patient who is sent from a physician to a diagnostic or therapeutic outpatient facility or to a specific hospital outpatient department for the diagnosis and treatment of an illness or injury.

1. Doctor who sends the patient for testing or treatment noted on the insurance claim when submitted by the physician performing the service. 2. When completing the CMS-1500, the referring physician’s complete name and degree is inserted in Block 17 and his or her national provider identifier (NPI) is placed in Block 17a of the paper claim form.