Pathway Warm-Up
Intake confirms eligibility, builds the authorization correctly, uploads and links all required documents, and completes the Intake note.
What is the next pathway?
Pathway: Proceed to Review
Owner: Intake
Next action: Route the completed authorization to Review and confirm that the task reached the correct queue.
Intake does not approve the request. Intake prepares a complete, review-ready record.
Who verifies eligibility on the PAR receipt date, checks administrative readiness, and builds the authorization shell?
Owner: Intake
These are administrative functions. Intake authority ends when the completed authorization is routed to Review.
A required signed lease is completely missing when Intake reviews the submission.
RFI or not?
Yes - Administrative RFI
The missing item is specific, necessary, and correctable.
A provider submits Specialized Case Management, T1023, as a prior authorization request.
What is the correct pathway?
Pathway: Do not build it as an HSS prior authorization
Owner: Intake
Next action: Follow the approved claim-only or provider-guidance pathway.
SCM may support the HSS record, but it is not built as an HSS prior authorization.
Sarah is building Maria Lemos’s HRD authorization. The PAR, UHAT, HSP, HCP, income documentation, deposit invoice, FMR support, and active HTS approval are present. The signed lease is missing.
Choose the pathway.
Pathway: Administrative RFI
Owner: Sarah acting in Intake
Next action: Request the signed lease, document the RFI, create the follow-up task, and maintain Pending status.
The answer is based on one question: Is the missing item specific, required, and correctable before Review? Yes.
Review confirms that the Member is eligible, the requested service is covered, sequencing is valid, all required documents are linked, and no RFI remains open.
What is the pathway?
Pathway: Approval
Owner: Review Staff with determination authority
Next action: Complete the Review fields, notes, rationale, determination, and correct approval notice.
Approval is appropriate only when the entire record supports it—not simply because most documents are present.
Who applies HSS requirements, validates sequencing, and selects the determination pathway?
Owner: Review Staff with determination authority
Task ownership does not automatically create determination authority.
The lease is uploaded in TruCare but was not linked to the authorization or line item.
RFI or not?
No RFI for the provider. Correct the internal record.
Pathway: Stop and correct
Owner: The staff member responsible for the current workflow stage
Next action: Link the document correctly and confirm that it can be relied upon.
Do not ask the provider to resend information the plan already received simply because staff did not complete the internal linkage.
During an HTS review, staff discover that the Member may have previously used the Housing-Related Deposit benefit.
Should HTS be denied or delayed?
No.
Pathway: Continue the HTS review using HTS requirements
Owner: Review
Next action: Document the deposit-history finding and update or escalate the utilization tracking issue as required.
Prior deposit use does not deny, limit, or delay Housing Transition Supports.
Alma receives the missing lease for Toni Peitz. The document is uploaded, linked, and confirms the same amount, address, landlord, and move-in date shown in the other documents.
What happens next?
Pathway: Satisfy and close the Administrative RFI, then proceed to Review
Owner: Alma acting in Intake
Next action: Document what was received, confirm the RFI is fully resolved, close the RFI, and route the authorization to Review.
Receiving a document does not automatically resolve the RFI. Staff must validate that it answers the actual request.
A Housing-Related Deposit request arrives without the signed lease. The lease is required to confirm the housing arrangement and deposit obligation.
What is the pathway?
Pathway: Administrative RFI
Owner: Intake
Next action: Request the signed lease, create the required RFI follow-up, and keep the authorization Pending.
The missing document is identifiable, correctable, and needed before the request is ready for Review.
The provider submitted an illegible PAR, and the service dates cannot be read.
Who owns the next action, and what is it?
Pathway: Administrative RFI
Owner: Intake
Next action: Request a legible or corrected PAR before completing the shell build.
The issue prevents accurate administrative entry and does not require Review judgment.
During Review, the lease identifies a $900 deposit, but the landlord invoice requests $1,400. Clarification could change the approved amount.
RFI or not?
Yes - Review RFI
Owner: Review
Next action: Request documentation resolving the amount discrepancy.
The conflict is material to the determination and payment support.
An HRD request is submitted. The record clearly confirms that the Member does not have active, concurrent HTS.
What is the pathway?
Pathway: Review-level adverse or administrative denial pathway
Owner: Review
Next action: Document that the required dependency is not met and complete the appropriate escalation and notice controls.
Do not issue an RFI when the record clearly establishes that the sequencing requirement is not met.
Monique reviews Roger Gentless’s HRD request. All requirements are supported, active HTS is confirmed, no prior HRD utilization is found, and no RFI remains open.
Choose the pathway.
Pathway: Approval
Owner: Monique acting with Review authority
Next action: Complete the Review documentation, approve the supported amount, issue the correct notice, and add the applicable review and approval alerts.
Approval is the result of complete validation—not the starting assumption.
Review confirms that the requested expense is ongoing monthly rent. The benefit does not cover ongoing rent, and additional documents would not change that fact.
What is the pathway?
Pathway: Administrative denial pathway
Owner: Review
Next action: Document the exclusion, complete required escalation or secondary review, and use the approved adverse correspondence pathway.
Do not issue an RFI when the correct outcome is already clear. An RFI is not used to postpone an adverse decision.
During Review, the HSP and lease contain conflicting move-in dates. The correct date could affect whether sequencing and service timing are supported.
Who owns the next action?
Pathway: Review RFI
Owner: Review
Next action: Request clarification or corrected documentation needed to resolve the material conflict.
The information is present, but Review cannot apply the requirements defensibly until the conflict is resolved.
The RFI due date passed. Required information was not received, and the record still cannot support a determination.
What is the pathway?
Pathway: Admin Denial
Owner: Review
Next action: Confirm that required RFI and extension controls were completed, document the missing information, and complete required escalation before adverse action.
Intake does not deny the request because the provider failed to respond.
A Sustainment request is submitted, but the documents do not establish whether housing has been secured. The provider may have omitted the lease.
What is the pathway?
Pathway: Administrative RFI or Review RFI, depending on when the omission is identified
Owner: Intake if the required document is absent before Review; Review if clarification is needed to validate the service stage
Next action: Obtain the information needed to confirm that housing is secured.
The correct RFI owner depends on the workflow stage and whether the issue is administrative presence or Review-level validation.
An HRD authorization was approved yesterday. There is no claim, payment confirmation, landlord receipt, or other evidence that the approved benefit was used.
Which Member status is accurate?
Status: HRD approved; utilization not yet confirmed
Pathway: Continue post-approval tracking
Owner: Assigned HSS or Review staff under the approved workflow
Next action: Do not mark the lifetime benefit as consumed until utilization is supported.
Approval and utilization are two separate events.
Staff cannot determine which queue should receive the request, and the available TruCare configuration does not allow the service information to be entered accurately.
What is the pathway?
Pathway: Stop and escalate
Owner: Intake or Review, depending on where the problem is discovered
Next action: Document the configuration or routing issue and escalate it to the designated operational or configuration owner.
Review determines that the request cannot be fully approved and may require a partial approval or adverse action.
Who owns each stage?
Initial analysis: Review
Required secondary or adverse review: Medical Director or other designated authority when required
Notice guidance: G&A or UM when the correct adverse notice pathway is unclear
Review identifies and documents the issue. Required escalation must be completed before the adverse determination or notice is finalized.
Review confirms that the requested item is room and board, which is excluded. The provider’s documentation is complete.
Should Review issue an RFI for more justification?
No.
Pathway: Adverse or administrative denial pathway
Owner: Review
Next action: Document the excluded request and complete the required determination, escalation, and notice controls.
An RFI must not be used to search for a reason to approve or delay a clearly supported adverse pathway.
An authorization contains both H0043 and H0044 line items because the provider requested both services on the same PAR.
What is the pathway?
Pathway: Stop and correct the authorization structure
Owner: Intake if found during build; Review must return or escalate it if found later
Next action: Create separate authorization records for each service type.
One HSS service type belongs on each authorization record. Provider submission format does not override the authorization-structure rule.
A reviewer opens an authorization and finds:
What is the correct pathway?
Pathway: Stop and correct or escalate before any determination
Owner: Intake must resolve Intake-level issues; Review must obtain correct ownership before Review activity
Next actions:
The correct response is not to decide faster. It is to restore record integrity before deciding.