GUIDELINES for Referral to Medical Case Management Cases meeting the following “Red Flag” criteria should be referred to medical case management. Referral shall be made following the attached guidelines by using the attached referral form in either paper or electronic format. RED FLAGS FOR REFERRAL • CATASTROPHIC INJURIES (amputations, xxxxx fractures, head injuries, spinal cord) • HOSPITALIZATION CASES (with potential complications, i.e.: diabetes, CHF, HTN) • 3 OR MORE PRIOR WORKERS’ COMPENSATION CLAIMS • INPATIENT PROCEDURES – DIAGNOSTIC TESTS (where medical necessity is in question) • HISTORY OF MULTIPLE NON-INDUSTRIAL INJURIES • ANY CLAIM WITH COMPLEX MEDICAL ISSUES (drug use, multiple treaters, no change in condition, excessive lost time, etc.) • ASSAULT CASES WITH MORE THAN SIX WEEKS OF DISABILITY • REPETITIVE STRAIN INJURIES • CASES INVOLVING UNREPRESENTED APPLICANTS WITH INDEMNITY RESERVES GREATER THAN $50,000. • INAPPROPRIATE MEDICAL TREATMENT (overutilization, failure to provide reports, six months with no change in medical condition) • ANY CASE WHERE THE ADJUSTER FEELS THE MEDICAL OR MED/PYSCH/SOCIAL ISSUES WILL INTERFERE WITH APPROPRIATE TREATMENT OR DELAY APPROPRIATE RECOVERY CASES THAT SHOULD NOT BE REFERRED TO CASE MANAGEMENT: • Minor Injuries ( minor laceration, minor sprains, etc) • Medical-only cases • Delayed cases • Denied cases • Litigated cases where cooperation from an applicant attorney is unlikely. • Cases where the safety of the nurse may be jeopardized. REFERRAL PROCESS The Referral Form – (either electronic or manual) is to be completed with the contact numbers of the adjuster, the claimant and the medical provider. • Check the box for Field on all cases. • Send or fax the last 90 days of medical reports as well as any recent AME /QME reports to the person listed on the vendor contact sheet. • Complete the Comments Section and indicate the purpose of case management. (Complete the Special Instructions section on the electronic form.) • Example: Field Case Management: RN to meet with the treating physician and the injured worker to determine the post –op treatment plan. (R rotator cuff repair on 3/27/01). Identify PPO vendors for PT and DME, identify work restrictions and obtain target date for return to work (RTW) modified duty and full duty. • Send or fax the original referral form to the person listed on the vendor contact list, submit a copy of the referral form to your supervisor. DO NOT FAX CASES DIRECTLY TO THE CASE MANAGER. • The Contractor is ...
GUIDELINES for Referral. When a physician has a patient who has a blood pressure that is not at goal, the Physician can refer the patient to the Pharmacist for counseling. The physician will document the referral in their progress note in the medical chart. The patient will make an appointment to meet with the Pharmacist at a later time and/or date. Depending on the schedule of the Pharmacist and the patient, the Pharmacist may see the patient immediately on the same day. Patients in established ongoing care relationship with the Provider can be seen by the pharmacist blood pressure management as well. If there are any doubts about an ongoing relationship, this must be confirmed by the Pharmacist. In instances when the primary care physician is not the immediate referring provider, the primary care physician will be notified of the referral to the clinical pharmacist.
GUIDELINES for Referral. The provider(s) at Physician/Clinic may refer any patient: With uncontrolled hypertension Recently diagnosed with hypertension Receiving multiple medications and carrying a hypertension diagnosis Experiencing an adverse effect secondary to drugs used to treat hypertension Having difficulty understanding and/or adhering to their hypertension medication regimen Patient may self-refer. Referrals are made by selecting the medication therapy management option on the check-out sheet.
