NO REFERRAL ON FILE DENIAL IN MEDICAL BILLING

 In this post we are going discuss about no referral on file scenario in medical billing by PCP name we can understand that there is no referral so that's what we will get this denial from insurance.

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What is the concept of referral? Referral is nothing but an approval given by the Primary Care Provider to the patient to consult a specialist. The PCP [Primary Care Provider] is also known as a gatekeeper family doctor and referring doctor.

The patient will first go to the PCP and get the referral number after that the patient should consult a specialist for treatment this is a concept of referral.  

What is free call analysis on referral now before calling to insurance company we need to check our doctor software for referral number is there or not and also what is the type of member plan? If patient plan is HMO then referral is mandatory from PCP if patient plan is PPO no referral is required because there is no PCP in PPO plan.

Now coming to AR follow first point call to insurance company and provide the referral number over the phone call and confirm whether that referral whatever you provided is valid or not.  

Scenario -1 [Valid Referral]: If referral is valid then reprocess the claim over the call so your task is done.

Scenario -2 [Not Valid Referral]: If referral is not valid ask the insurance representative and get the details like what is a PCP name specialty and what is the PCP phone number these are useful to get the obtained referral in further ask the insurance representative for corrected claim mailing address to submit the claim with valid referral obtain also get claims appeal mailing address to send an appeal.

Third point is that reprocess after you obtain a valid referral submit a corrected claim to the insurance company with valid referral number.

Last point is send an appeal if you confirmed that build services does not require any referral you discussed with your physician and also you confirmed with your physician or your doctor that whatever we build services to the insurance does not require any referral in that confirmation you can send an appeal to the insurance this medical services doesn't require any referral.