Housekeeping
True or False. Timesheets are due Sunday.
Home Health aide reports that when arriving to provide service today the member's home appears to be abandoned and there is a eviction notice on the door. When checking with AMHA they report that logs show his key fob has not been used since June.
Individual Lost/Missing
This is the maximum time allowed to enter a critical incident after the CMA or RMA becomes aware.
Within 1 business day
A provider performs services before they are authorized in the person-centered services plan
Failure to Coordinate Service Delivery - Failure to provide PCSP-authorized services
While entering an incident report an incorrect Medicaid number is on the report. I go here to find the correct Medicaid number.
HIP
Clarification is needed from a Care Coordinator to complete a PCG Task. The IMT staff uses these to reach out for the information.
Email Templates
A member was taken to the emergency room for feeling nauseous. While there they reported that they were taking a multivitamin 5x/day.
Medication Error - Critical
This document identifies circumstances or behaviors that may jeopardize an individual’s health and welfare and specifies interventions to reduce those risks.
Health Safety Action Plan (HSAP)
A WSC reports that she received an email from a Home Health Agency on Monday that member's aide did not report last Thursday because her car broke down.
Failure to Coordinate Service Delivery - Failure to notify when service is not provided
PCG asks for an authorization during the time of the incident. I go here to find the authorization.
HIP - Service Plan or UM Tile. If not there; TMV.
I set my time to show as this in the IMT calendar when I will be out of the office.
Free
Member reports that she noticed a ring and some mints missing from her dresser. The only person in her house that day was her home health aide.
Misappropriation
Unauthorized restraint, restrictive intervention, or seclusion falls under this critical incident category.
Behavioral Support Misuse
A home health agency reports that they haven't received payment from Anthem. The CC finds that the agency had been using the wrong billing code and provided the agency with the correct billing code.
Non-Fraud Billing Issues - Clerical authorization, documentation or EVV error
A member is showing in HIP as non-waiver but an incident report comes from a My Care CC. I go here to check eligibility and enrollment dates.
PNM
While I am covering for a IMT member out of office I am responsible for addressing these items related to their cases.
PCG Tasks
The member reported that he was recently evicted and is currently homeless, stating that he is staying in his vehicle with his three dogs. The member also reported that he does not have money to feed himself or put gas in his car. Additionally, he reported that he is without shoes.
HSW Risk Housing/Eviction Crisis
Money or property is taken from an individual through deception, intimidation, or misuse of authority.
Exploitation
A CC reports that a provider is having issues with payment for services last month. In review of authorized services and billing claims she finds that the member had a brief hospital stay she was unaware of during that time but there are also claims for home health services during the same timeframe.
Medicaid Fraud - Billing for services not rendered and Failure to Coordinate Service Delivery - Failure to notify when service is not provided.
PCG is asking for claims during the timeframe of a provider occurrence. I go here to find the claims.
TMV
I have entered a case in IMS. Now I update the case in Sharepoint by doing these two things.
Enter IMS Case Number & switch case to Open.
A IR for Self-Neglect was submitted. A member is refusing to shower and lays on her couch, not getting up for most of the day. She leaves her dishes and throws her trash on the floor. The member has had several agencies discontinue service due to the smell and the state of the house. True or False - I would enter this in IMS.
False - Self Neglect is not a OAC incident definition.
An individual’s primary caregiver is unexpectedly hospitalized and no backup caregiver is available, placing the individual’s essential care and safety at risk.
Loss of Caregiver
A member reports that yesterday his aide arrived with her sister. The aide and her sister stayed the entire scheduled shift but while they were there they spent more time on his front porch talking. He was upset because he heard them talking about his recent hospital stay.
Prohibited Provider Behavior - Prohibited conduct while rendering services and Unprofessional Behavior of the Provider - Failure to comply with HIPAA or confidentiality
PCG is asking for the correct NPI number as the provider name is not matching anything in their records. This may be the issue and I can go here to find the correct number.
The provider may be dba under a different name. Check TMV for authorizations and review authorizations for provider dba information. If still unsure a quick google search of the named provider may reveal the correct NPI and dba information or could be found on their website.