ACUTE REVIEW
If you have a DRG Par Facility and it is approved at low on the initial review, when does the case switch to high?
Where do you go to complete your TBTs
Learning Hub
What case note do you use if you have an HCA facility readmission review and the MD says to link it?
HCA Readmission Review
Who do you task P2P letters that will expire over the weekend to?
Kelly Smith RN
In what scenarios would you follow the cancellation process for post acute authorizations?
Duplicate auth- same level of care
True clerical error was not intended to be requested
Discharge planning case note
Discharge planning template
Correspondence Create case note
Where do you go to find CRGs to join and expand your network within CVS
To join a Colleague Resource Group:
Go to Workday.
From the Menu, select the Quick Links.
Select Change Colleague Resource Group.
Select Add to join a CRG.
Under the Name section, use the search box to find CRG as the Affiliation type.
Select the name for the CRG you are interested in joining and relationship (Member).
What instances would you not follow the readmission flag for an acute case review?
Facilities listed on the Provider Deviation list require the UMNC to follow their specific deviation language.
The DRG re-admission policy applies when staff conducts the initial admission review and may apply even if the decision is outside standard turn-around times (e.g., >72 hours from notification).
This does not apply to per diem, percentage billed, critical access hospitals or any Maryland facility.
Non-DRG Contracts
Transfers for a higher level of care. These are NOT readmissions and should not be linked under the readmission review policy (applies to acute care facilities only).
When you are reviewing an IPR auth, and the facility is on the UM Exempt list, what are the steps for review?
• If no clinical is submitted, approve 7 days per clinician.
• A QB is still required for the initial clinician review.
• Document “unknown” for any fields where clinical information is not available.
• Rationale should read: “Approving per facility contract – UM exempt.”
For post-acute cases, in your eligibility note:
• Document “UM Exempt per Deviation list”
• You may also paste the relevant contract from SCM if available.
When reviewing a pdiem par facility auth, what is the criteria you are using for the review?
CMS
What is the name of the resource/hub for Nurses to expand on career goals, network within the company
Enterprise Nurses Hub
When reviewing an acute authorization, if MC says the facility is NON PAR, but SCM shows the facility has a DRG Contract, which process do you follow?
What is the name of resource on the heartbeat page for mental health support that is no cost to you or household members?
Resources for Living
For acute denial letters, who's responsibility is to review the plain language in the long text for the denial letters?
Even though the MD’s are writing the verbiage, it is the responsibility of the UMNC to verify its accuracy and return it to the MD for any necessary revisions. As always send these letters to your AM/TL for final review of plain language and any needed assistance w/ correction of plain language.
Where do you complete your mid year and end of year self evaluations
Workday