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Referral Claims Capture

SDAHO Enterprises’ Endorsed Business Partner, SunRx, is an expert in 340B. In a recent blog post, the company explores 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.

Other questions that are answered in the blog post include:

  • Why can a Covered Entity capture referral prescriptions?
  • Why should a Covered Entity consider capturing referral prescriptions?
  • What does the Covered Entity need to do to be able to capture referral claims?
  • What is the process to capture referral claims?
Click here to read the full post.

About SunRx

SUNRx is a healthcare technology company that assists healthcare facilities with 340B administration, including split billing and 340B contract pharmacy network administration. Our technology helps facilities optimize their supply chain and pharmacy operations and we help simplify complex program administration for Covered Entities. Based in San Diego, CA SUNRx has been managing 340B programs since 2006. With SUNRx, you’ll receive industry-leading expertise and hands-on customer support. It’s 340B. Simplified. To learn more visit sunrx.com/who-we-are.

The SDAHO Enterprises Endorsed Business Partner program was established to provide innovative and cost-effective solutions for our member hospitals and long-term care facilities across the healthcare continuum. The business partners selected are expected to meet high-quality standards and offer products or services which are designed to assist healthcare facilities avoid costs, recover revenue, reduce operating and capital expenses, improve management and quality, increase productivity, develop staff resources and apply new innovative strategies.

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