The Alabama Medicaid Referral Form (Form 362) is a crucial document used by healthcare providers to facilitate patient referrals within the Alabama Medicaid program. This form captures essential information about the patient, primary physician, and the specifics of the referral, ensuring that all parties involved are informed and coordinated. Proper completion of this form is vital for effective patient care and adherence to Medicaid guidelines.
The Alabama Medicaid Referral form, officially known as Form 362, serves as a crucial document in the healthcare process for Medicaid recipients in Alabama. This form is designed to facilitate referrals from primary care physicians to specialists, ensuring that patients receive the necessary care tailored to their specific medical needs. Key components of the form include essential recipient information such as the patient's name, Medicaid number, and contact details, which must be accurately filled out to avoid processing delays. The primary physician's information, including their National Provider Identifier (NPI), is also required, along with a signature to validate the referral. Different types of referrals can be indicated, including those for Patient 1st recipients, EPSDT screenings, and case management services. Each referral type has specific instructions and implications for billing, which are outlined in the accompanying Medicaid Provider Manual. Additionally, the form allows for the specification of the length of the referral and the nature of services to be provided, whether it be evaluation only, treatment only, or a combination of both. The consultant’s information is also captured, ensuring that communication between the specialist and the primary physician is seamless. Finally, the form includes a section for the primary physician to indicate how they wish to receive findings from the consultant, emphasizing the importance of clear communication in patient care.
2/23/12
Instructions for Completing
The Alabama Medicaid Agency Referral Form (Form 362)
TODAY’S DATE: Date form completed
REFERRAL DATE: Date referral becomes effective
RECIPIENT INFORMATION:
Patient’s name, Medicaid number, date of birth, address, telephone number and parent’s/guardian’s name
PRIMARY PHYSICIAN:* Provide all PMP information. For hard copy referrals, the printed, typed, or stamped name of the primary care physicians with an original signature of the physician or designee is required. Stamped or copied signatures will not be accepted. For electronic referrals provider certification is made via standardized electronic signature protocol.
SCREENING PROVIDER:* Screening provider (if different from primary physician) must complete and sign if the referral is the result of an EPSDT screening.
*NPI INFORMATION: Provide NPI number. For billing purposes indicate Medicaid Provider number, if available.
TYPE OF REFERRAL:
◆Patient 1st - Referral to consultant for Patient 1st recipient only (See *Chapter 39 for Claim Filing Instructions).
◆EPSDT - Referral resulting from an EPSDT screening of a child not in the Patient 1st program - indicate screening date (See *Appendix A for Claim Filing Instructions).
◆Case Management/Care Coordination - Referral for case management services through Patient 1st
Care Coordinators (See *Chapter 39 for Claim Filing Instructions).
◆Lock-In - Referral for recipients on lock-in status who are locked in to one doctor and/or one pharmacy (See *Chapter 3 -3.3.2 for Claim Filing Instructions).
◆Patient 1st/EPSDT - Referral is a result of an EPSDT screening of a child who is in the Patient 1st program - indicate screening date (See *Appendix A for Claim Filing Instructions).
◆Other - For recipients who are not in Patient 1st program.
LENGTH OF REFERRAL: Indicate the number of visits/length of time for which the referral is valid.
Note: Must be completed for the referral to be valid.
REFERRAL VALID FOR:
◆Evaluation Only - Consultant will evaluate and provide findings to Primary Physician (PMP).
◆Evaluation and Treatment - Consultant can evaluate and treat for diagnosis listed on the referral.
♦Referral by Consultant to Other Provider For Identified Condition (Cascading Referral) - After evaluation, consultant may, using
Primary Physician’s (PMP) provider number, refer recipient to another specialist as indicated for the condition identified on the referral form.
◆Referral by Consultant To Other Provider For Additional Conditions Diagnosed By Consultant (Cascading Referral) - Consultant may refer recipient to another specialist for other diagnosed conditions without having to get an additional referral from
the Primary Physician (PMP).
◆Treatment Only - Consultant will treat for diagnosis listed on referral.
◆Hospital Care (Outpatient) - Consultant may provide care in an outpatient setting.
◆Performance of Interperiodic Screening (if necessary) - Consultant may perform an interperiodic screening if a condition was diagnosed that will require continued care or future follow-up visits.
REASON FOR REFERRAL BY PRIMARY PHYSICIAN (PMP):
Indicate the reason/condition the recipient is being referred.
OTHER CONDITIONS/DIAGNOSIS IDENTIFIED BY PRIMARY PHYSICIAN:
Indicate any condition present at the time of initial exam by PMP.
CONSULTANT INFORMATION: Consultant’s name, address and telephone number.
PLEASE SUBMIT FINDINGS TO PRIMARY PHYSICIAN BY: The Primary Physician (PMP) should indicate how he/she wants to be notified by the consultant of findings and/or treatment rendered.
*The Alabama Medicaid Provider Manual is available on the Alabama Medicaid website| at http://www.medicaid.alabama.gov/CONTENT/6.0_Providers/6.7_Manuals.aspx
2-23-12
ALABAMA MEDICAID REFERRAL FORM
Today’s Date _________________
PHI-CONFIDENTIAL
Date Referral Begins _________________
Important NPI Information
(If different from above)
MEDICAID RECIPIENT INFORMATION
See Instructions
Recipient Name
Recipient #
Recipient DOB
Address
Telephone # with Area Code
Name of Parent/Guardian
PRIMARY PHYSICIAN (PMP) INFORMATION
SCREENING PROVIDER IF DIFFERENT FROM PRIMARY PHYSICIAN (PMP)
Name
Fax # with Area Code
Email
NPI #
Medicaid Provider #
Signature
TYPE OF REFERRAL
Patient 1st
Lock-in
EPSDT
Screening Date ______________________
Other
Case Management/Care Coordination
LENGTH OF REFERRAL
Referral Valid for __________ month(s) or __________ visit(s) from date referral begins.
REFERRAL VALID FOR
Evaluation Only
Treatment Only
Evaluation and Treatment
Hospital Care (Outpatient)
Referral by consultant to other provider for identified
Performance of Interperiodic Screening (if necessary)
condition (cascading referral)
Referral by consultant to other provider for additional conditions diagnosed by consultant (EPSDT Only)
Reason for referral by PMP
Other conditions/diagnoses identified by PMP
CONSULTANT INFORMATION
Consultant Name
Consultant Telephone # with Area Code
Note: Please submit written report of findings including the date of examination/service, diagnosis, and consultant signature to Primary Physician (PMP).
Findings should be submitted to Primary Physician (PMP) by
Mail
E-mail
Fax
In addition, please telephone
Form 362
Alabama Medicaid Agency
Rev. 2-23-12
www.medicaid.alabama.gov
Al Cpt 2023 Instructions - By centralizing business information in a single document, the form assists in the coordination between different state departments and agencies regarding business oversight.
How to Get a Work Permit in Alabama - An important document for students in Alabama, granting them the opportunity to work based on their school performance.
To ensure a comprehensive understanding of the responsibilities outlined in the Washington Hold Harmless Agreement, it is advisable to consult additional resources and fill out the necessary documentation, such as the one provided by WA Documents, which can guide you through the process effectively.
Electronic Title Transfer - Crucial for bypassing probate court while transferring a vehicle title from someone who has passed away in Alabama.