Perform referral management for members
How perform referral management for members are reshaped as AGI capability advances.
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Perform referral management for members 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 Perform referral management for members inherits.
Where Perform referral management for members sits
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How the work flows
Trigger: A primary care provider or member submits a request for a referral to a specialist or specialized medical service.
- Receive and log the referral request from the provider or member
- Verify member eligibility and active benefit plan rules
- Check provider network status to ensure the requested specialist is in-network
- Evaluate the request against clinical guidelines and administrative policies
- Issue an approval, modification, or denial for the referral
- Transmit the referral decision to the requesting provider, receiving specialist, and member
- Update the core administrative system to link the authorized referral to future claims
Outcome: The referral request is adjudicated and recorded in the core system to govern future claims processing, and all parties are notified of the decision.