Thank you for your inquiry on CMS50v11 Closing the Referral Loop: Receipt of Specialist Report. To address your first question, the measure does not look for a different eligible clinician who may have placed a referral for a mutual patient during the measurement period. Your second interpretation is correct. “First referral” signifies the first referral each eligible clinician makes for a single patient. In the scenario where a single clinician makes multiple referrals for a patient, only the first referral that clinician makes can meet or fail to meet the numerator criteria. In the scenario where there are two separate clinicians who refer a patient to the same specialty, then each of their referral loops would be closed when the specialty sends a report back to the referring clinician. If the specialty sent back a report to only one of the clinicians, then only that clinician had the referral loop closed. To address your second question, if a referral is placed on or before October 31, the consultant report can be collected at any point during the measurement year, up to and including 11:59pm on December 31.