Referral Claims Capture

Capturing referral claims is no doubt an important step to take to optimize 340B savings in your program. Here, we will define what a referral claim is, and why a covered entity can and should be capturing many of these prescriptions, and how to capture referral claims.

What is a referral prescription or claim?

Often, primary care providers will refer a patient to another provider for a second opinion or treatment diagnosis or condition that requires advanced or specialized care. Most patient referrals are to specialty providers such as endocrinology, infectious diseases, rheumatology, dermatology, etc. – and which are not directly employed by the 340B covered entity but the covered entity has established an arrangement with. These patients continue to remain under the care of their primary care provider at the covered entity. The referring provider usually makes the arrangements for their patient to be seen by the specialty provider (e.g., make the appointment) but the specialty provider may or may not always provide any notes back to the referring provider. It is best practice for these referral specialty providers to send a note or letter back to the patient’s primary care provider, summarizing their diagnosis and treatment plan and any medications they have prescribed. Any prescription medication prescribed by the specialty provider is called a referral claim.

Published 08/01/2023

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Bubba Bartlett
(619) 890-9462