Senior living · Referral intake
Hospital referral intake for nursing homes, home health, hospice and home care
Hospital referral intake is a race against the clock. A discharge planner with a patient ready to leave often calls several providers and needs a clear answer fast. Your AI receptionist answers referral calls when admissions can’t. It takes the few details that belong on a phone call, says where to send the packet and puts the call through by your rules.
Free 7-day trial, no card. For HIPAA-covered providers, with a business associate agreement you accept in the portal. HIPAA and the rules in your state
Why the first call matters in hospital referral intake
Hospitals give patients a list of providers and a choice. Then the planner needs an answer, often the same day.
Under the hospital discharge planning rule, the discharge plan includes a list of available skilled nursing facilities, home health agencies and other post-acute providers. The hospital must respect the patient’s freedom to choose among them (42 CFR 482.43(d)). In practice, a discharge planner or case manager with a patient ready to go often sends the referral to several providers on that list at once.
A provider that responds quickly, with a clear next step, is easier for a planner to work with. Evening and Friday discharges make that harder: the planner is still working after your admissions office has gone home.
Your virtual receptionist answers those calls when your team can’t: after hours, on weekends, or when the admissions phone rings out.
What it never decides
It doesn’t accept or decline a patient, promise a bed, check insurance or read a clinical record. Your admissions team and clinicians decide every referral.
What the agent asks on the phone vs. what stays in the referral packet
The packet carries the clinical story. The call only needs enough for admissions to call back and find the packet.
| Detail | On the phone | In the packet |
|---|---|---|
| Who is calling | Name and role: discharge planner, case manager, nurse, physician office or family | The referring physician or provider’s details |
| Where from | The hospital and unit, or the health plan | Facility and contact details |
| Call-back | A direct number, and how late they’re working today | — |
| Care needed | The type of care, in the caller’s words: short-term rehab, long-term care, home health, hospice, home care | Diagnosis and reason for placement; therapy needs |
| Timing | The expected discharge date, and whether it could be today or tomorrow | Details of the recent hospital stay |
| Payer | The payer as the caller states it: Medicare, a Medicare Advantage plan, Medicaid, private pay | Payer and insurance information; authorization requirements |
| Patient | Not by default; add initials in step 3 if admissions needs them | Identifying and demographic details |
| Clinical detail | None: no medications, diagnoses or isolation status read out on the call | Medication list; isolation or infection-control needs; supporting documents |
| Where to send it | Your secure referral channel, read from your rules | — |
The packet column follows the intake checklist in SNF Metrics’ guide to incoming referrals. HIPAA’s minimum necessary standard doesn’t apply to disclosures to a provider for treatment. Keeping clinical detail in the packet is a workflow choice: it lands where your team reviews it. General information, not legal or clinical advice. Rules differ by state and province and change over time, so check yours.
Discharge planner calls after hours, and the four other referral calls
Five callers, five endings. In each, the agent takes the same short set of details and leaves the decision to your team.
A referral call comes in. The greeting says it’s an AI and that the call is recorded.
- Hospital discharge planner
I have a patient going home Monday who needs short-term rehab. Do you have a bed?
Your virtual receptionistDoesn’t answer the bed question. Takes the six details and reads back where to send the packet.The call endsPut through to admissions, or a referral for admissionsYour team receivesA call record in the portal, and an email saying a call came in.Nursing home answering service - Health plan case manager
I’m with the health plan. Our member needs a skilled nursing placement.
Your virtual receptionistTakes the plan name and the case manager’s direct line with the other details. Never says whether the plan will approve the stay.The call endsA referral for admissionsYour team receivesThe plan and a direct number, so admissions can start on the authorization. - Physician office
Dr. Patel’s office. We want to refer a patient for home health.
Your virtual receptionistTakes the office, the contact and the type of care, and says where orders and notes should go.The call endsA referral for intakeYour team receivesA call record with the office’s call-back number. - Family self-referral
My dad is in the hospital, and they said we need to pick a nursing home.
Your virtual receptionistTakes the caller’s details and the hospital’s name. Suggests the hospital’s case manager send the referral. Answers general questions from your rules.The call endsA message for admissionsYour team receivesA call record marked as a family call, with the hospital’s name.Questions for a family’s first call - Emergency department, after hours
ED case manager here. Can you take a patient tonight?
Your virtual receptionistNever says yes. Takes the details and puts the call through to your on-call admissions number, if your rules allow night admissions.The call endsPut through, or a referral for admissionsYour team receivesA live call, or a call record in the portal; the email only says a call came in.
Quotes are examples. One agent puts calls through to one number. If nobody answers within 20 seconds, the agent takes the referral as a message, and your team is notified by email.
Referral intake for hospice and home health: the clocks behind the call
Home health and hospice referrals often run on days, not weeks. The phone call is where that clock first shows.
Home health. Medicare’s home health rules set the timing of the initial assessment visit. It happens within 48 hours of referral or of the patient’s return home, or on the start-of-care date the physician or allowed practitioner ordered (42 CFR 484.55(a)(1)). A referral that waits in voicemail over a weekend eats into that window.
Hospice. Hospices must make nursing services, physician services, and drugs and biologicals routinely available on a 24-hour basis, 7 days a week (42 CFR 418.100(c)(2)). So many hospices take referrals at night. Your rules decide whether the agent puts a night referral through to the on-call line or takes it as a message for intake.
Home care. Non-medical home care referrals often ask for a start within days. The agent takes the same details, with the payer as stated.
One line or two
One agent puts calls through to one number. To send referrals to admissions and care calls to the nurse on call, build a second agent with its own number: a dedicated referral line.
The referral call record in your portal
Every referral arrives as a call record in your 365vox portal, laid out the same way each time: the six details first, then the summary, transcript and recording. With an EHR or admissions system that has an open API, connected in step 5, Integrations, the details and call notes also go straight into it.
For an agent that hears health information, the call email only says that a call came in. The details stay in your 365vox portal, behind your sign-in. Calls your rules mark urgent are flagged urgent in the portal and get their own email. For a health agent, that email only says an urgent call came in; the details stay in the portal. A rule that marks referrals with a discharge in the next two days urgent keeps a Friday-evening referral from sitting under the day’s routine messages.
Referral: short-term rehab, discharge Monday, Lakeview General
- Caller
- Jordan Ellis, discharge planner · (614) 555-0172, direct line · working until 7 PM
- Calling from
- Lakeview General Hospital (example), 4 West
- Care needed
- Short-term rehab after a hospital stay (caller’s words)
- Expected discharge
- Monday, November 2. Could be Saturday if a bed is found.
- Payer, as stated
- A Medicare Advantage plan. Caller says authorization is in progress.
- Packet
- Told to send it to your secure referral fax (from your rules)
- Put through
- Yes, to the admissions nurse on call, at 4:55 PM
- Caller was told
- Admissions reviews every referral and decides (your rules). The agent discussed no bed or start date.
SNF referral intake: the payer rules behind the questions
The agent takes the payer as stated, and nothing more: only admissions can check it.
- Traditional Medicare covers skilled nursing facility care after a medically necessary inpatient stay of at least 3 consecutive days, not counting the discharge day. Admission generally follows within 30 days of discharge (42 CFR 409.30). Admissions checks that; the agent records what the caller says.
- Medicare Advantage plans can require authorization for a SNF stay. An HHS Office of Inspector General review of 19 plans found they denied 12% of requests for SNF admission in June 2024. Only 18% of denials were appealed, and plans overturned 95% of those (Generations, July 2026, citing the OIG).
- Medicaid, private pay and long-term care insurance each have their own rules. The agent records the payer in the caller’s words, never says whether it covers a stay and never turns a referral away over it.
Rules change
General information, not legal or clinical advice. Rules differ by state and province and change over time, so check yours. Medicare Advantage authorization rules differ by plan. Keep the payer list in your business rules current.
What it never does on a referral call
Never accepts or declines a patient
Clinical review and payer checks decide that. The agent tells the caller who decides and what happens next, from your rules.
Never offers a bed or a start date
Unless your rules say otherwise. Bed availability changes by the hour and business rules don’t, so it’s safer to leave it out.
Never takes the clinical packet by phone
No medication lists, diagnoses or isolation status read aloud. It tells the caller where the packet goes: your secure fax, portal or email.
Never calls the hospital back
It answers incoming calls only. Your admissions team returns the call; the record says who called, from where, and how late they’re working.
Build it yourself
Build a home health referral intake line, or one for your SNF or hospice
Referral callers share health information. When you create the agent, answer Yes to “Will callers share health information with this agent?” and accept the health-information agreement. Then set these on the Customize screen.
You set all of this yourself in the 365vox portal, on the Customize screen. Everything saves as you type; then you submit, test the agent with a real call and activate it.
Customize · your agent
- Step 1, IndustryOther. Your greeting, questions and rules carry the referral detail.
- Step 2, GreetingName the line:
Thanks for calling Lakeview Rehabilitation’s referral line. I’m an AI assistant, and this call is recorded.
The portal checks that it says both. - Step 3, Questions to askName and phone are there; keep email if hospitals send referrals that way. Then add four:
Which hospital, unit or health plan are you calling from?
,What type of care does the patient need?
,What’s the expected discharge date?
andWhat’s the payer, as you understand it?
- Step 4, Forward to a personYour admissions phone, or the cell carried by the admissions nurse on call. One number per agent. If nobody answers within 20 seconds, the agent takes the referral as a message.
- Step 5, IntegrationsYour EHR or admissions system, if it has an open API: the referral details and call notes go straight into it. You can start without one.
- Step 7, When your agent answersOverflow: your admissions phone rings first, and the agent answers if nobody picks up within 20 seconds. Or 24/7 for a dedicated referral number.
- Step 8, Call notificationsThe admissions director, the intake coordinator and the on-call inbox. The emails say a call came in; the details are in the portal.
- Step 9, Business rulesWhere packets go, admissions hours, when to put calls through, the payers you accept, and the starter rules below.
- Step 10, Things your agent will never doThe five built-in rules stay on. Add
Never say a bed, a start date or an admission is available.
Starter rules for your referral intake line
Paste these into step 9, Business rules, then fill in the brackets. Have your admissions director and privacy officer read them first.
Business rules · referral intake (starting point)
Starting point only: review with your clinicians and your privacy officer before you use it. Referral calls come from hospital discharge planners, health plan case managers, physician offices, emergency departments and families. On a referral call, ask only for: the caller’s name and role; the hospital, unit or health plan; a direct call-back number; the type of care needed; the expected discharge date; and the payer as the caller states it. Do not ask for diagnoses, medications, isolation status, Social Security numbers, Medicare numbers or member IDs. If the caller starts reading clinical details, say: “Please put that in the referral packet so our admissions team can review it.” Tell every referral caller where to send the packet: [your secure referral fax number, referral portal or secure email]. Never accept or decline a patient. Never say a bed, a start date or an admission is available. Say: “Our admissions team reviews every referral and decides. They’ll call you back.” [Between 8 a.m. and 8 p.m., every day,] put referral calls through to admissions. If nobody answers within 20 seconds, take the referral as a message and say our admissions team will call back. At other times, take the referral and say our admissions team will call back [first thing in the morning]. If an emergency department is asking about an admission tonight, put the call through. If a family member calls about a referral, take their name, number and the hospital’s name. Suggest they ask the hospital’s case manager to send the referral to us. Answer general questions from these rules only. We accept [Medicare, Medicaid, these Medicare Advantage plans, private pay, long-term care insurance]. If the caller names a payer that isn’t listed, take the details and say admissions will check.
About 1,800 characters of the 4,000 that step 9 allows.
What a referral line costs
$0.75 a conversation minute, billed by the second. No monthly plan, no setup fee and no long-term contract. Taxes where applicable. Referral calls stay short when the clinical detail goes in the packet.
Example: 60 referral calls a month
A 120-bed skilled nursing facility, with the agent answering when admissions doesn’t pick up.
- Referral calls a month
- 60
- Average call
- 3 min
60 calls × 3 min × $0.75 = $135, plus taxes where applicable. Illustrative numbers chosen by 365vox: your cost follows your own calls.
Comparing virtual receptionist services?
Live answering services usually sell monthly plans of minutes or calls. 365vox is an AI virtual receptionist that answers forwarded calls on the first ring, day and night, follows your approved answers and costs $0.75 a minute, billed by the second, with no plan.
More for post-acute and senior care providers
Hospital referral intake FAQs
What is hospital referral intake, and why does speed matter?
Can the agent tell a discharge planner whether we have a bed?
Should a referral call include the patient’s name?
How do SNF referral intake calls differ from home health or hospice referrals?
What happens when admissions doesn’t answer the transfer?
Can hospitals send the referral packet through the AI?
Does a referral intake line need a business associate agreement?
What does a referral intake line cost for a 120-bed SNF?
The planner is still working at 5. Answer the referral.
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