REFERRAL TO OUTSIDE PROVIDERS FOR STUDENTS COVERED BY UC SHIP *

Effective Date: 
Mon, 07/01/1996
Reviewed: 
Fri, 01/08/2021
Revised: 
Fri, 01/08/2021
Policy: 

Student Health Services (SHS) clinical staff provides primary care for UCSC students. Patients with UC SHIP requiring consultation or care from a provider not available at SHS are referred after evaluation by a primary care provider (PCP). A referral is created by the PCP to communicate clinical history, reason for referral, to authorize referral for insurance purposes, and to instruct the specialist to send information back to the referring clinician.  Further visits require a follow up visit with the referring provider or another SHC career primary care provider for re-evaluation unless the clinician specifies something other in writing on the referral.  Referrals are made for management of a specific diagnosis.  Unless clinically required, referrals are to specify the type of specialty care rather than a specific provider, i.e. GI vs. Dr. Smith.

Referrals from SHS to a specialist are limited to six visits unless the PCP specifies differently in the clinical history and on the referral.  For notes from physical therapy, where they have assessed that more than 6 visits are required, insurance staff can extend the referral to meet the needed extra visits or prn as documented by PT.

When a patient needs a stat consultation, it is the responsibility of the PCP to communicate and arrange care with the outside specialist office with assistance of the charge nurse. The insurance office will be called or paged whenever there is a stat referral for faxing.

The Insurance staff will track high risk referrals if this is designated on the referral.

Insurance staff will assist patients with urgent (1-2 weeks) and non-urgent referrals, per PnC designation on the referrals.

Note: Referrals are not provided for students with CruzCare and NoSHIP because UCSC SHC is not the primary care provider for students with private insurance.  In these cases, outside specialties will not accept our referrals since they need authorization from the insurance plan.

NOTE: CAPS refers students to outside mental health providers for one year as does the SHC for ongoing specialty treatments like endocrinology, allergy immunotherapy etc.

Procedure: 

Patients will start care at the SHC for an evaluation by a primary care clinician who does initial work-up of the case and determines any need for specialty care. The clinician composes a referral in the EMR.  Unless otherwise noted in writing on the referral, this is a six visit referral. This can be overridden for the following specialties: oncology, hematology, nephrology, neurology, rheumatology, endocrinology, and immunotherapy. For stat or very serious conditions, the clinician facilitates the referral process and can solicit assistance from the charge nurse to telephone the specialist’s office and arrange an appointment for the patient (see attachments).  Stat referrals require same day communication between the SHC referring clinician and the specialist assuming care. The insurance staff can send the referral and any supporting documents via calling or paging insurance.

For non-urgent referrals, the clinician completes the referral and visit notes by end of day and directs the patient to SHS Insurance the same day to assist with communicating with the specialist's office to send any needed information and to help schedule an appointment. SHS Insurance Staff will send the referral, using SFAX, and the supporting documentation to the specialists' offices that clinicians attach to the referral and SHS Insurance staff change referral status to "sent."

For continuity of care, a medical progress summary needs to accompany the student to the SHC re-evalution appointment or can be faxed to the UCSC SHS Medical Records at 831-459-3546, where the documents will be scanned into the EMR.  The SHS clinician will review the progress/summary of care, and typically in an appointment, help with the options for continued specialist treatment, which requires a new referral, or offer different beneficial approaches.  NOTE: for physical therapy or chiropractic care, students need to be informed that X-rays are covered and are no fee at the SHC, but if done outside are subject to the current deductible and then coinsurance after the deductible.

REFERRAL RENEWALS

Renewals require a clinician visit. This visit should be with the patient's PCP if the student has a regular career SHC primary care provider, or choose the provider who made the referral, the SHS staff will recommend follow up with with that SHC provider.  If the student does not have a primary care provider at the SHC, then the SHS staff will provide names for a career MD/DO and a NP/PA-C provider/s team (not per diem staff) for the follow up.  Insurance office staff will request appropriate documentation from the specialty office to support the request for renewal.

Process:

  • Medical Records request to specialist's office
  • Advocate reviews the referral and either generates a new referral, a retro-referral or edits an old referral for additional visits
  • Admin Note in PnC stating: date of service, type of referral i.e. renewal, retro, new
  • Advocate documents appropriate information
  • Documents sent to Medical Records
  • Retro-referrals are added to the "Retro-Referral" Spreadsheet

TRACKING

Referrals are designated as "track" when the clinician identifies high risk conditions requiring follow up. SHS Insurance staff will track these referrals and document the follow up when a specialist consultation note is not received within 30 days of the referral.  The clinician will be informed of tracking efforts if consultation notes are not received.  Depending on the clinical situation and risk, the clinician will send a registered letter to the patient prior to terminating tracking efforts for patients who do not follow through with recommended specialty consultation.

See the attached forms or policies for the responsibilities in the referral process.

Key Points: 
  • Patients are referred to specialty providers outside the Student Health Center when required care is not available at the Student Health Center for students with UC SHIP.  Six (6) appointments will be authorized, unless noted otherwise, then a follow up assessment must be performed at the SHC.  If continued care is needed from the specialist, the SHC clinician will write another referral
  • Assisting with specialist appointments and insurance information are an important part of our comprehensive clinical care
  • Patients referred for significant problems are tracked at the discretion of the referring clinican
  • The Student Health Insurance Office will assist with referrals
  • Referrals are not provided for students with CruzCare and NoSHIP