# Transmitting Referrals Referrals need to be securely transmitted to receiving providers. This can be done using various methods depending on the technical capabilities of the receiving system. The [`Communication`](/content/docs/api/fhir/resources/communication/index.html) resource is used to represent the transmission event, including details about the sender, recipient, and payload. For recipients without a FHIR API, a [`Bot`](/content/docs/bots/index.html) can be used to generate and send a PDF of the referral information. ### C-CDA Transitions of Care For interoperability with external systems, referrals often need to be transmitted as C-CDA (Consolidated Clinical Document Architecture) documents. The Transitions of Care template is specifically designed for referral scenarios and includes structured sections for: - Reason for referral - Current medications - Allergies and adverse reactions - Problem list - Relevant diagnostic results - Care plan and instructions See the [C-CDA Transitions of Care documentation](/content/docs/integration/c-cda#transitions-of-care/index.html) for implementation details on generating standards-compliant referral documents. ```typescript // Example of generating a C-CDA Transitions of Care document for a referral const ccdaDocument = await medplum.generateCCDA({ patient: patientReference, templateType: 'transitions-of-care', serviceRequest: serviceRequestReference, includeSection: [ 'reason-for-referral', 'medications', 'allergies', 'problems', 'results', 'care-plan' ] }); ``` ## Essential Referral Data Requirements ### Clinical Documentation Requirements Successful referrals require comprehensive clinical documentation to ensure: - **Specialist acceptance**: Clear justification for the referral - **Insurance authorization**: Medical necessity documentation - **Reimbursement compliance**: Proper diagnostic and procedural coding - **Continuity of care**: Complete clinical context transfer ### Core Data Elements | **Category** | **Required Elements** | **FHIR Resources** | **Billing Impact** | |---------------------------|-----------------------------------------------------------|------------------------------------------------------------------------------------|------------------------------------------| | **Patient Demographics** | Name, DOB, MRN, Insurance ID | [`Patient`](/content/docs/api/fhir/resources/patient/index.html) | Required for claims processing | | **Clinical Justification**| Primary/secondary diagnoses with ICD-10 codes | [`Condition`](/content/docs/api/fhir/resources/condition/index.html) | Medical necessity for authorization | | **Diagnostic Evidence** | Lab results, imaging reports, diagnostic tests | [`Observation`](/content/docs/api/fhir/resources/observation/index.html), [`DiagnosticReport`](/content/docs/api/fhir/resources/diagnosticreport/index.html) | Supports medical necessity | | **Treatment History** | Previous interventions, medications tried | [`MedicationRequest`](/content/docs/api/fhir/resources/medicationrequest/index.html), [`Procedure`](/content/docs/api/fhir/resources/procedure/index.html) | Demonstrates step therapy compliance | | **Current Medications** | Active prescriptions with dosages | [`MedicationRequest`](/content/docs/api/fhir/resources/medicationrequest/index.html) | Drug interaction screening | | **Allergies & Intolerances** | Known allergies and adverse reactions | [`AllergyIntolerance`](/content/docs/api/fhir/resources/allergyintolerance/index.html) | Safety screening | | **Insurance Information** | Coverage details, authorization requirements | [`Coverage`](/content/docs/api/fhir/resources/coverage/index.html) | Claims processing and authorization | ## Tracking Referral Status Once a referral has been sent, it's important to track its status through the entire lifecycle. The [`Task`](/content/docs/api/fhir/resources/task/index.html) resource is ideal for this purpose, as it provides a standard way to represent workflow status. Requested Authorization Pending Authorized Accepted Rejected Scheduled In Progress Completed ### Enhanced Status Tracking The Task resource should include business-specific status information: ```json { "resourceType": "Task", "businessStatus": { "coding": [ { "system": "http://example.org/referral-status", "code": "prior-auth-pending", "display": "Prior authorization pending" } ] }, "statusReason": { "text": "Waiting for insurance authorization - submitted 2024-01-15" } } ``` ### Diagnostic Report Transfer When diagnostic reports are required for the referral, ensure proper linkage: ```json { "resourceType": "DiagnosticReport", "id": "ecg-report-for-referral", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "CUS", "display": "Cardiology" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "11524-6", "display": "EKG study" } ] }, "basedOn": [ { "reference": "ServiceRequest/cardiology-referral-example" } ], "presentedForm": [ { "contentType": "application/pdf", "data": "JVBERi0xLjMKJcTl8uXrp...", "title": "ECG Report - John Smith" } ] } ``` ## Specialist Response Integration When a specialist responds to a referral, their response can be captured as a [`DocumentReference`](/content/docs/api/fhir/resources/documentreference/index.html) and linked to the original referral through the [`ServiceRequest`](/content/docs/api/fhir/resources/servicerequest/index.html). If the response results in an appointment, an [`Appointment`](/content/docs/api/fhir/resources/appointment/index.html) resource can be created and linked to the referral. ### Billing Code Integration Specialist responses should include appropriate billing codes for services rendered: ```json { "resourceType": "Encounter", "id": "specialist-consultation", "status": "finished", "class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "AMB", "display": "ambulatory" }, "type": [ { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "99244", "display": "Office consultation for a new or established patient" } ] } ], "basedOn": [ { "reference": "ServiceRequest/cardiology-referral-example" } ], "diagnosis": [ { "condition": { "reference": "Condition/final-cardiac-diagnosis" }, "use": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis-role", "code": "AD", "display": "Admission diagnosis" } ] } } ] } ``` ## Example Specialist Response ```json { "resourceType": "DocumentReference", "id": "specialist-response-example", "status": "current", "docStatus": "final", "type": { "coding": [ { "system": "http://loinc.org", "code": "11488-4", "display": "Consultation note" } ] }, "subject": { "reference": "Patient/example-patient-id", "display": "John Smith" }, "date": "2023-06-15T10:00:00Z", "author": [ { "reference": "Practitioner/cardiologist-id", "display": "Dr. Helen Cardio" } ], "authenticator": { "reference": "Practitioner/cardiologist-id", "display": "Dr. Helen Cardio" }, "content": [ { "attachment": { "contentType": "application/pdf", "data": "JVBERi0xLjMKJcTl8uXrp...", "title": "Cardiology Consultation Report - John Smith", "creation": "2023-06-15T10:00:00Z" } } ], "context": { "related": [ { "reference": "ServiceRequest/cardiology-referral-example" } ] } } ```