CEG
You pull a Medical Records Required Aetna Medicare case and see the webuser has copy/pasted the entire LOV into a web note instead of attaching it as an upload. How do you proceed?
Utilize the clinical provided. Medicare cases follow normal case processing rules.
Your first step upon opening attached clinical
Verify HIPAA
The non-MRR case you are working has an upload attached and notes the member has prior history of Coronary Artery Disease (CAD). The UPADS states the member does NOT have history of CAD. Which will you document?
Upload only. If a fax/upload is present in the case, UPADS should not be counted when there is a discrepancy.
Use this button in CDP to refresh your case
Select
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Ctrl+F
True or False: ASAP is scribbled on the fax cover page of the Medicare case you're working. You should review the clinical for this case to determine if you can update the case to Priority U.
True: The reason the imaging is being done ASAP (i.e. due to medical urgency, scheduling, etc.)
For a more efficient review of attached clinical, use this version of the fax/upload and take advantage of the highlighter, copy and paste, and/or search functions.
OCR
You pull a Multi-CPT case containing a CT Abdomen/Pelvis and MRI Lower Extremity. The indication for CT fits the specialty you're trained in, but the MRI does not. How do you proceed?
Review all codes contained in the request regardless of specialty. Multi-CPT cases may be built with mixed competencies. For any GL questions, contact GCS.
CBR Routing provides you with this information
Case specialty
Application used to streamline documentation; specialty templates and keyboard shortcuts live here
eviNotes
Document only this when new clinical is present and a previous Nurse Reviewer Note has already been documented.
Any relevant new/additional clinical
This section of the most recent OV note may be the most helpful in determining the rule out or reason for imaging.
Assessment and Plan
The written case you've been assigned is already in Urgent Priority. How do you determine if this case should remain in Priority U, or if you should downgrade to Priority R?
Utilize CEG: Urgent Processing to first determine if the HP/specialty allows downgrading. If yes, proceed to Urgent Fax Request Verbiage and Medical Urgent Guidelines
Checking this on every case will help you determine if there are same or similar studies to factor into your review
Case History (sometimes called Member History)
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How do you proceed when there is a request to make a Medicare case Urgent, but the case is an easy approval?
Do not make a clinical decision until it is placed in Urgent priority.
Decrease the time spent on documenting prior imaging results by focusing on this part of the imaging report
Impression
FIDA is a type of Medicare and Medicaid plan that should never be placed into which status?
Hold (Status H)
Use this button in CDP to easily determine if a case has previously been held
Pri Pg 4
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Right click Citrix Workspace icon > Advanced Preferences > Reset Citrix Workspace
How many notes are required when offering Coding Redirection on a written case?
2 notes: 1 note containing clinical provided + hold note using the CPT Code Redirection Template
You are assigned a case via Get Next Case in which Attachment A & B were reviewed by a previous CR who then sent the case to MD Review. Attachment C & D have since been added. Which attachments are you responsible for?
While you should not duplicate prior documentation, each CR assigned to a case is responsible for reviewing/factoring in ALL the relevant clinical present at that time.
Explain the steps to holding a case that has some clinical present.
Complete a Nurse Reviewer Note (NRN) with the clinical provided, including GL used. Place case on hold, customizing the hold rationale to request the specific information missing. Major takeaway: TWO notes are required.
Select this button in CDP for a written Empire case after emailing GCS
Get Next Case
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