Processes
Manage provider referral
How manage provider referral are reshaped as AGI capability advances.
ProcessesManage provider referral
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Manage provider referral sits inside a larger value-flow — 1 parent structure it composes into. The hierarchy is grounding, not the story: it tells you which aggregate exposure Manage provider referral inherits.
Where Manage provider referral sits
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How the work flows
Trigger: A provider submits a referral request for a member to receive specialized medical care or services.
- Receive and log the referral request from the provider
- Verify member eligibility and active plan benefits
- Review the request against clinical guidelines and network tier constraints
- Determine approval, denial, or modification of the referral
- Assign an authorization number to approved referrals
- Transmit the referral decision to the providers and the member
Outcome: The referral request is adjudicated and the final determination is communicated to the requesting provider, receiving specialist, and member.
Measured by
Referral Turnaround TimeAuto-Adjudication RateOut-of-Network Referral RateReferral Denial Rate