1. Referral request - data classification Patient information – Patient demographics, covered by MU2 and CCDA requirements – Patient identifier (Med Rec Number) As known to the sender Common for both sender and receiver As known to the receiver – Two elements from spreadsheet don’t belong SSN should not be used for healthcare Medicare # - this is administrative information, belongs to insurance information

2. Referral request - data classification Referral administrative information – Referral Identifier (not present in the spreadsheet) – Referral Date Time period in which referral is expected to occur – Referral Approval obtained Insurance pre-authorization, if necessary (e.g. Yes/No, number) – Insurance information (multiple insurance policies/kinds possible) – usually covered in ADT or X12 messages Kind (primary, secondary, Medicare/Medicaid, Worker’s comp) Policy number Group number Insurance member ID (e.g. Medicare #) Guarantor/Subscriber/Insured demographics

3. Referral request - data classification Referring provider (sender) information Receiving provider information Patient’s PCP and care team (if different from sender and receiver) – Information provided by provider directories Provider identifier – Direct address – NPI # Provider demographics Provider organization

4. Referral request - data classification Clinical information – Reason for referral – Referring or transitioning provider's name and office contact information – MU2 specified clinical information Problems (SNOMED-CT value set) Medications (RxNorm) Medication allergies (RxNorm) Laboratory test(s) (LOINC) Laboratory value(s)/result(s) Vital signs (height, weight, blood pressure, BMI) Care plan field(s), including goals and instructions Procedures (SNOMED-CT or HCPCS/CPT-4), optional CDT, optional ICD-10-PCS Care team members, including the PCP Encounter diagnosis (ICD-10-CM or SNOMED-CT) Immunizations (HL7 Standard Code Set CVX) Functional status, including activities of daily living, cognitive/disability status – Additional clinical information (depending on specialty)