RFI Mistakes
RFI issued. Two documents received. Reviewer closes RFI and proceeds to approval. One requested document is still missing.
What went wrong?
Partial receipt does not close an RFI; no determination may proceed while an applicable RFI remains active.
All documentation is present and supports approval. Reviewer issues RFI anyway.
What went wrong?
If the record already supports a clear approval pathway, a Review RFI should not be issued.
Document uploaded but not linked. Reviewer references it in notes.
What went wrong?
Relied-upon documents must be uploaded and linked. Uploaded but unlinked records are treated as not reviewed.
Determination entered. Notice not issued.
What went wrong?
A required notice is missing. Determination alone is not enough when the workflow requires correspondence.
Review Summary: “Request supported.”
Rationale: “Documentation incomplete.”
Determination: Approved.
What went wrong?
The documentation set is misaligned. Review Summary, Rationale, and determination must tell the same story.
Reviewer issues RFI asking for “anything else that might support approval.”
What went wrong?
An RFI must be necessary, relevant, and specific. It cannot be vague or used to search for extra reasons to approve or deny.
Requirements clearly do not support approval. Reviewer issues RFI instead of following the denial pathway.
What went wrong?
RFI cannot be used to delay a clear adverse pathway. If the correct pathway is already clear, staff must follow Decision Logic.
All steps seem complete, but one open RFI task still exists. Record closed.
What went wrong?
A record must not be closed with unresolved tasks or active RFIs. Final validation requires a clean task state.
Notice says “approved.” Determination says “denied.”
What went wrong?
The notice does not match the determination. Correspondence must align with determination fields, Review Summary, Review Notes, and Rationale.
Review Notes describe a missing lease. Rationale supports approval anyway.
What went wrong?
The rationale is unsupported by the documented record. Approval requires complete, linked documentation.
RFI is active. Reviewer enters denial and sends notice.
What went wrong?
No determination or notice should proceed while an applicable RFI remains active.
A request has an unresolved duplicate/blocking issue and unclear next step, but staff approves it anyway.
What went wrong?
When the pathway is unclear or a blocking issue remains unresolved, staff must stop and follow the appropriate pathway rather than proceed to determination.
Record approved, but no clear rationale explains why.
What went wrong?
The record must be defensible and reconstructable. Review documentation must clearly explain what was reviewed, what was decided, and why.
Notice issued before final record validation.
What went wrong?
The SOP says not to issue correspondence before the final pathway is validated and the TruCare determination is complete.
Review Notes cite a file name that was never uploaded or linked.
What went wrong?
If a document is relied on, it must be uploaded and linked. Notes must cite exact file names only for documents actually in the record.
Reviewer issues a Review RFI even though the record already clearly supports denial.
What went wrong?
A Review RFI must not be used when the correct pathway is already clear. If the requirements are clearly not met and more information would not change the outcome, staff should follow Decision Logic and the adverse pathway.
RFI response is incomplete. Reviewer approves anyway because “most of it came back.”
What went wrong?
If the RFI response is partial or still insufficient, staff must keep the RFI open or move to the appropriate next pathway after reapplying Decision Logic. Approval cannot proceed without a defensible record.
Approved H0044 record has no claims/payment note and no updated alert.
What went wrong?
For approved H0044, the record must include the itemized approved amount, claims/payment note when required, and deposit tracking/alert updates. Approval and utilization must remain distinct.
Required letter did not populate, so staff used a different template just to finish the case.
What went wrong?
If the required letter does not populate, staff must stop and escalate. They must not substitute another template.
Claims/payment note for approved H0044 does not match the approved amount breakdown in the record.
What went wrong?
For H0044, the claims/payment note must align with the approved authorization amount, itemized breakdown, supporting documentation, payee, payment direction, determination fields, and notice language.
RFI response received. Documents uploaded, but not linked. Reviewer closes the RFI.
What went wrong?
Before closing an RFI, staff must confirm the documents were received, uploaded, linked, cited, and that the issue is fully resolved. Uploaded but unlinked documents are not sufficient.
The reviewer changes the pathway during Review but leaves the old Review Summary, Notes, and Rationale in place.
What went wrong?
If the pathway changes during Review, the Review Summary, Review Notes, Rationale, determination fields, and notice selection must all be updated before final action.
Record is closed even though the notice does not match the determination.
What went wrong?
Final validation requires determination, rationale, and notice to align before closure. Records must not be closed while any notice/documentation element is misaligned.
Denial notice sent, but required appeal-rights language is missing.
What went wrong?
The SOP says notice must not issue if required appeal-rights language is missing.
RFI history, Review Notes, Rationale, determination, and notice all tell slightly different stories.
What went wrong?
The record is not aligned or defensible. The SOP requires these elements to align before final action.