Date:	April 8, 2010
To:	Specialists
From:	Dale Bishop, MD, Medical Director
Subject:	Ensuring Correct Processing of Payments for Specialist Office Visits
Plans:	Medi-Cal, Healthy Families, Healthy Kids, AIM, Healthy Connections, County of San Joaquin Select, and San Joaquin County Premier

In order to ensure timely and correct processing of claims for specialist consultation, evaluation and management (E&M Codes) visits, be sure to remind your billing staff that the primary care physician (PCP) assigned to the patient must be listed on the Specialist Referral Form. The PCP is the physician named on the patient’s current ID card.

As a reminder, the specialty referral process is as follows:

The PCP will complete the Specialist Referral Form (available on DRE) and send the form directly to you. In order for your claim to be paid you should:

1. Include the patient’s PCP (which should be the referring physician) and the PCP’s NPI number on the form. (The PCP name is placed into box 17 and the NPI number into box 17b),
2. Be contracted with the patient’s plan (Medi-Cal, Healthy Families, San Joaquin County Select, etc.),
3. Confirm that the referred patient is eligible to receive benefits at the time of visit (check DRE). If you do not have access to DRE please contact Provider Services.

   REMINDER: Specialist Referral does not apply to out of area ancillary services. Authorization continues to be required.

   We continue to strive to process your claims more quickly and accurately than any of our competitors. Your assistance with reminding your staff to complete the Specialist Referral Form correctly and include the PCP & PCP NPI number will help us to accomplish this goal. Please address any questions or concerns to Provider Services at (209) 942-6340.