Follow the Clues
You receive a Housing-Related Deposit request.
The PAR and documentation have not been opened yet.
What's the first clue you should look for?
Verify Member eligibility on the PAR receipt date.
Every review begins with eligibility. If this requirement isn't met, the reviewer shouldn't continue working through the rest of the case.
A good detective starts with the biggest clue first.
The lease says:
Deposit = $1,800
The landlord invoice says:
Deposit = $2,300
What's bothering the detective?
The documentation conflicts.
Clarification is needed before continuing.
Eligible.
SCM complete.
HTS complete.
Documentation complete.
No prior utilization has been reviewed and documented in notes and as an alert.
Yes.
Continue toward Administrative Approval.
Member not eligible.
Administrative Denial.
Why do we check utilization?
To verify program limits have not already been met and to prevent duplicate Housing-Related Deposit authorizations.
Eligibility is confirmed.
The Housing Support Plan recommends a deposit.
The provider tells you, "Trust me, we've already done Transition."
Nothing in the record confirms HTS.
Do you keep reviewing?
No.
Verify that SCM and Housing Transition Supports have been completed or meet the program's sequencing requirements before continuing.
Never replace documentation with assumptions.
The Housing Support Plan recommends Deposit.
Under Social Risk Criteria on the UHAT "N/A Does not meet these criteria" is selected.
What's the concern?
.
Member does not appear to qualify for Housing Supports and Services.
The UHAT must indicate Member is either Homelessness or At risk of homelessness.
N/A disqualifies them.
Eligible.
No HTS.
Provider requests Deposit.
No.
Verify service sequencing and determine whether HTS is required before Deposit can move forward.
Required lease missing.
RFI.
You approve a Housing-Related Deposit request.
Your review note says:"Approved. Requirements met."
If Kevin asked, "How do you know the requirements were met?" could your documentation answer that question?
No.
The documentation should explain:
A reviewer shouldn't assume others know what they reviewed.
Your notes are your testimony.
Everything appears complete.
The Housing Support Plan says:
Member needs a deposit.
No lease.
No landlord documentation.
Would you approve?
No.
The reviewer does not yet have enough evidence to support the deposit request.
Need ≠ proof.
The documentation should support both the need and the amount.
The PAR requests Deposit.
No HTS authorization can be found.
What's your next move?
Verify service sequencing before determining the pathway.
Everything complete.
Member already received a Housing-Related Deposit within the allowable program limits.
Stop.
Review utilization and determine the appropriate administrative pathway.
Deposit exceeds FMR.
Complete FMR and cost reasonableness review.
Six months from now Yesenia opens your authorization.
She has never met the Member.
She wasn't part of the review.
She only has TruCare.
What should she NOT have to do?
She should not have to guess.
She should not have to call you.
She should not have to search emails.
She should not have to assume why the decision was made.
Everything needed to understand the determination should already be documented.
If someone has to investigate your investigation...
Your report wasn't finished.
The apartment is beautiful.
The landlord is willing to hold it.
The Member loves it.
The rent exceeds FMR.
What should the reviewer think before making a decision?
Complete the required FMR and cost reasonableness review.
Do not approve or deny based on the rent amount alone.
One number does not tell the whole story.
Everything matches...
Except the apartment address is different on the lease than on the PAR.
What is your next move?
Resolve the discrepancy before continuing.
Small inconsistencies become big problems during audits.
Everything complete.
FMR review not documented.
Stop.
Complete the required FMR review first.
Duplicate Housing-Related Deposit alert on Member file.
Review utilization history and determine whether the request duplicates a previous benefit before selecting a pathway.
A reviewer completed an approval. Everything appears perfect. Eligibility, SCM, HTS, UHAT, Housing Support Plan and Crisis Plan, Lease, Deposit documentation, FMR, Cost reasonableness, Utilization, Claim Information, Notice
One year later an external auditor reviews the case.
The auditor says, "I believe the reviewer followed the workflow..."
"...but I cannot determine WHY they approved this request."
What was the reviewer's biggest mistake?
The reviewer documented what they did but not why they did it.
A defensible review explains:
A completed workflow is not the same as a defensible determination.
The reviewer should always answer one final question before closing the case:
"If someone challenged this decision a year from now, would my documentation defend itself?"
You've completed everything.
As you're about to approve...
You notice an alert showing a previous Housing-Related Deposit at the Members last MCO.
What's your next move?
Pause.
Review the Member's utilization history and determine whether the alert represents a previous approved deposit, a duplicate, or another situation requiring review.
Alerts are clues.
Reviewers investigate them before deciding.
The PAR requests a Housing-Related Deposit.
The Housing Support Plan states: "Member is actively searching for permanent housing."
The lease submitted with the PAR is signed and shows a move-in date that occurred three months ago.
What doesn't add up?
The documentation tells two different stories about where the Member is in the housing process.
Before making a determination, the reviewer should clarify the Member's current housing status and determine whether the requested service and documentation still align.
When the timeline doesn't make sense, stop and investigate before choosing a pathway.
Everything complete.
Claim information has not been entered.
Do not finalize the request.
Complete the required claim information step according to the workflow.
A correct review is not complete until all required system steps are complete.
Everything supports approval. What are your next steps as a reviewer?
Complete:
before completing the authorization.
Before clicking Complete, finish this sentence:
"I know this case is ready because..."