CurrentsanfranciscohealthplanPolicy N/A

Personnel Training: Prior Authorization / Referrals

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Governs procedures and expectations for clinic/site personnel to process and track internal and external referrals, ensure receipt of specialist/procedure reports, and maintain referral documentation for Primary Care Physician (PCP) sites affiliated with San Francisco Health Plan.

Policy Summary

Payersanfranciscohealthplan

PolicyPersonnel Training: Prior Authorization / Referrals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a Referral Tracking Log or appropriate tickler system and ensure specialist/procedure reports are filed in the patient medical record within 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysmaximum time for specialist/procedure report to be filed in patient's medical record

Referral Tracking Logrequired system or tickler for PCP offices

Facility Site Reviewdocument aligns with DHCS site review and medical record review requirements

Referral Handling and Documentation Requirements

Referral handling and documentation requirements

Sites must maintain organized, timely referral systems and ensure availability of referral resources and documentation.

Maintain an organized referral system to make and track referrals, review consultant/specialist reports, schedule and provide follow-up care, and file reports in the patient medical record.

Systems, practices, and procedures used for handling referrals may vary by site.

Ensure referral informational resources (e.g., Health Plan Specialty and Network Directory) are readily available to site personnel.

Maintain appropriate referral forms at the PCP site; the practitioner shall complete the referral form and attach all relevant medical information.

Maintain a Referral Tracking Log or an appropriate tickler system to monitor referral status, appointment outcomes, and follow-up actions.

Ensure specialist or procedure reports are filed in the patient medical record within 30 days of the procedure or appointment; if the report is not received within 30 days, PCP staff will contact the specialist or procedure site to request a copy of the report.>= 30 days

Be prepared to demonstrate the office referral process from beginning to end (e.g., walk-through) during site review or quality assessment.

Coding and Report Timeframes

Not specifiedmixed

No codes listed

Report receipt timeframe

Report receipt timeframeReports must be filed in the patient’s medical record within 30 days from the date of the procedure or appointment; if not received within 30 days, PCP staff will contact the specialist or procedure site to request the report.

Action when report missingPCP/staff will contact the specialist or procedure site to request a copy of the report if not received within 30 days.

ScopeApplies to specialist or medical procedure reports associated with referrals managed by PCP sites.

Authorizations and Provider Resources

Note

Authorizations resource

See the SFHP page on Authorizations for the Health Plan's authorization procedures and resources.

Definitions and Office Tools

PCP site review

Regulatory referencePrimary Care Practitioner (PCP) site review requirement referenced under California Department of Health Care Services Title 22, Section 53230 and DHCS All Plan Letter 20-006.

PurposeSupports facility site review and medical record review expectations for PCP sites to demonstrate referral processes and documentation.

Related expectationsSite staff should be able to demonstrate the office referral process from beginning to end during reviews.

Referral Tracking Log

Required systemPrimary Care Physician offices are required to maintain a "Referral Tracking Log" or an appropriate tickler system to monitor referrals and follow-up.

Contents recommendedReferral Tracking Log should include patient name, date of referral, referral type, appointment date, and whether appointment was kept or failed.

PurposeUsed to track referral status, ensure receipt of specialist/procedure reports, and support follow-up care scheduling.

LocationReferral forms and tracking log must be available and maintained at the Primary Care Physician site.

Policy Summary

Payersanfranciscohealthplan

PolicyPersonnel Training: Prior Authorization / Referrals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a Referral Tracking Log or appropriate tickler system and ensure specialist/procedure reports are filed in the patient medical record within 30 days.

SourceLink

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OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentsanfranciscohealthplanPolicy N/A

Personnel Training: Prior Authorization / Referrals

Customize your policy alerts

Sign up for all sanfranciscohealthplan policy alerts

Know when sanfranciscohealthplan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payersanfranciscohealthplan

PolicyPersonnel Training: Prior Authorization / Referrals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a Referral Tracking Log or appropriate tickler system and ensure specialist/procedure reports are filed in the patient medical record within 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysmaximum time for specialist/procedure report to be filed in patient's medical record

Referral Tracking Logrequired system or tickler for PCP offices

Facility Site Reviewdocument aligns with DHCS site review and medical record review requirements

Referral Handling and Documentation Requirements

Referral handling and documentation requirements

Sites must maintain organized, timely referral systems and ensure availability of referral resources and documentation.

Maintain an organized referral system to make and track referrals, review consultant/specialist reports, schedule and provide follow-up care, and file reports in the patient medical record.

Systems, practices, and procedures used for handling referrals may vary by site.

Ensure referral informational resources (e.g., Health Plan Specialty and Network Directory) are readily available to site personnel.

Maintain appropriate referral forms at the PCP site; the practitioner shall complete the referral form and attach all relevant medical information.

Maintain a Referral Tracking Log or an appropriate tickler system to monitor referral status, appointment outcomes, and follow-up actions.

Be prepared to demonstrate the office referral process from beginning to end (e.g., walk-through) during site review or quality assessment.

Coding and Report Timeframes

Not specifiedmixed

No codes listed

Report receipt timeframe

Action when report missingPCP/staff will contact the specialist or procedure site to request a copy of the report if not received within 30 days.

ScopeApplies to specialist or medical procedure reports associated with referrals managed by PCP sites.

Authorizations and Provider Resources

Note

Authorizations resource

See the SFHP page on Authorizations for the Health Plan's authorization procedures and resources.

Definitions and Office Tools

PCP site review

Regulatory referencePrimary Care Practitioner (PCP) site review requirement referenced under California Department of Health Care Services Title 22, Section 53230 and DHCS All Plan Letter 20-006.

PurposeSupports facility site review and medical record review expectations for PCP sites to demonstrate referral processes and documentation.

Related expectationsSite staff should be able to demonstrate the office referral process from beginning to end during reviews.

Referral Tracking Log

Required systemPrimary Care Physician offices are required to maintain a "Referral Tracking Log" or an appropriate tickler system to monitor referrals and follow-up.

Contents recommendedReferral Tracking Log should include patient name, date of referral, referral type, appointment date, and whether appointment was kept or failed.

PurposeUsed to track referral status, ensure receipt of specialist/procedure reports, and support follow-up care scheduling.

LocationReferral forms and tracking log must be available and maintained at the Primary Care Physician site.

Policy Summary

Payersanfranciscohealthplan

PolicyPersonnel Training: Prior Authorization / Referrals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a Referral Tracking Log or appropriate tickler system and ensure specialist/procedure reports are filed in the patient medical record within 30 days.

SourceLink

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