Case Processing
Normally, if any cases are left in the CR's worklist at the end of the day, this option can be used to clear the list.
What is Reject Case
This is used as a priority for patients who need prompt advanced imaging and 1 required criteria is met.
What is Customer Expedited?
If a provider requests both a CT Abdomen and CT Pelvis, this is the appropriate type of CPT code to use.
What is a combination code? (74176, 74177, 74178)
The caller states the member's name correctly, but states incorrect date of birth. These are other verification options.
What is Member address, member ID number, driver's license number or other government-issued ID, correct case number/episode ID, or phone number (with area code)?
True or False. You must always review the ACDS/UPADS note if present.
What is true?
This indicates eligibility cases may go through PI or Predictive Intelligence and state "Elig. Approved" on the CPT Line.
What is Rationale 897?
This is the first step to upgrading a case in ISAAC to urgent.
What is open the Agreement Section?
This is an offer of an alternative CPT code the nurse makes that may only be made by phone.
What is a Coding Redirection?
Amanda and Mandy, Anthony and Tony, and Camryn and Cam are examples of this.
What are approved nicknames or shortened names per HIPAA?
A case with an attachment in a foreign language would be directed to here.
What is emailed to evicoreclinicaloperationssupervisors@evicore.com?
This has occurred if pending additional, Medicare Hold, Hold for clinical, Denied-96, or Pending 96 shows completed or started on a case.
What is Pended a Case?
Urgent cases received without clinical information cannot be ______.
This template is utilized when there is a CPT Code Discrepancy and the case is unable to be pended.
What is Nurse CPT Discrepancy Fax Template?
When pending a case, these words must be present to ensure the case quickly routes if no new clinical is received after pending timeframe expires.
What is "To MD Review"?
When working a case that clearly states Workers Compensation on a Cigna health plan, this is what should be done.
What is Cancel the Case by using the Case Cancellation Notes Template?
Cases notes with red lettering that reads "Medical Records Required" generally requires this.
What is clinical records attached?
This is the internal urgent TAT for non-Medicare.
What is 4 hours for most health plans?
If a case is open or complete approved and there is an obvious coding error by eviCore staff, this is not needed on the case.
What is Medical Necessity Review?
During initial review, these 3 pieces of information must be in every Nurse Reviewer Note when approving a phone case.
What is the source of information/Caller's name and location, Guideline citation, and LOV?
This is the first step when working a case with illegible notes (exception to MRR).
What is attempt to contact the provider's office for assistance?
Emergent, acute, grave, life-threatening, critical are examples of this.
What is Urgent Fax verbiage?
If competency is not a match on an urgent case, call here for assistance.
What is GCS at extension 20615?
If a case was approved in error, this must be done with the authorization.
What is honor the authorization number generated in the case?
The following statement "(GL used) CXR may be indicated" would go here.
What is a nurse comment?
While working offline, you come across what appears to be a duplicate request. First request was approved by predictive intelligence. This would be your first step in processing the pending request.
What is call the MDO and verify; if unable to contact, pend for verification?