Patient 1st Referrals and EPSDT referral

Patient 1st Referrals

By verifying eligibility, providers can get information regarding whether a
recipient is enrolled in the Patient 1st program. If the recipient is enrolled in
Patient 1st, the provider must document information regarding the recipient’s
primary medical provider (PMP) and obtain a referral for services prior to
rendering services. A Patient 1st referral form is available; however, any
method of documenting the required information is acceptable. The referral
form must identify the PMP, the reason for the referral, authorized dates of
service, and name of staff member giving referral.

As a specialty provider, ASCs are required to obtain a referral from the
recipient’s PMP before rendering services. Without a referral from the PMP,
reimbursement cannot be made. Refer to Chapter 5, Filing Claims, for
specifics on completing the UB-04 claim form with this referral information.

9.3.2 EPSDT Referrals

Children under 21 years of age can receive medically necessary health care
diagnosis, treatment and/or other services to correct or improve conditions
identified during or as a result of an EPSDT screening. Refer to Appendix A,
EPSDT, for more specifics on obtaining these referrals.