What Path Fits?
A request meets all HSS requirements, documents are linked, no RFI is active, and the notice path is clear.
Administrative Approval, RFI, Administrative Denial, or Escalation?
Administrative Approval
Use approval when requirements are met and the record supports the request. Approval should be supported by eligibility, documentation, and aligned review fields and notice.
Who issues an Administrative RFI?
Intake
Administrative RFIs belong to Intake and address administrative readiness issues.
The record cannot be reconstructed from TruCare alone.
Stop
Record integrity is a hard stop. An uninvolved reviewer must be able to reconstruct the authorization.
The Housing Support Plan is missing.
RFI
Correctable missing information usually requires RFI, not denial.
What is the standard HSS authorization timeframe (TAT)?
48 hours (2 business days)
The standard HSS review timeframe is 48 hours from verified PAR receipt.
A required document is missing and receiving it could change the outcome.
Administrative Approval, RFI, Administrative Denial, or Escalation?
RFI
Use an RFI when information is missing, incomplete, unclear, or conflicting and that information is necessary to support a defensible decision.
Who issues a Review RFI?
Review Staff
Review RFIs are used when additional information is needed to support a review determination.
A required escalation has not been completed.
Stop
Determinations and notices cannot move forward when required escalation remains incomplete.
Documentation is blurry and unreadable.
RFI
Unreadable documents prevent review and should be corrected through RFI.
Can staff rely on information stored only in email or Teams?
No
Information used to support decisions must be documented in TruCare.
The reviewer identifies a potential policy exception.
Administrative Approval, RFI, Administrative Denial, or Escalation?
Escalate
Policy exceptions require escalation and secondary review before determination.
Can Intake approve or deny an authorization?
No
Intake authority ends at routing. Determinations are Review-level activities.
The HSS service and documentation do not align.
RFI
The service story must be clear before review can continue.
The reviewer already has enough information to deny.
Do not issue an RFI
An RFI should not be used when the outcome is already clear.
Should urgency ever replace required review steps?
No
Urgency never bypasses required workflow controls.
Documentation conflicts and tells two different stories.
Administrative Approval, RFI, Administrative Denial, or Escalation?
RFI
Conflicting documentation must be clarified before determination. Do not guess which document is correct.
Who validates that relied-upon documents are uploaded and linked before routing?
Intake
Intake must validate and link all relied-upon documents before routing.
A system field does not support the requested workflow.
Escalate
Staff must not force fields or use workarounds.
The missing information could change the outcome.
RFI
RFI is appropriate when the missing information could affect the review result.
Can a determination be entered while a Review RFI is active?
No
Applicable RFIs must be resolved before determination.
A request is outside the HSS benefit scope.
Administrative Approval, RFI, Administrative Denial, or Escalation?
Administrative Denial
Administrative Denial may be appropriate when a requested service or cost is outside HSS scope and approval cannot be supported.
Who updates Member Alerts during review activities?
Review Staff
Material HSS and HRD findings that affect benefit history or eligibility are maintained by Review.
The notice, determination, and rationale do not align.
Stop
All review documentation and correspondence must align before notice issuance.
The issue is not correctable and requirements clearly are not met.
Administrative Denial
When requirements are clearly not met, denial may be appropriate.
True or False: A completed Intake note replaces Review documentation.
False
The Intake note does not replace Review Summary, Review Notes, Outcome, or Rationale.