Review Process
Confidentiality/ Security & Conflict
TAT
Training
Telecommuter
100
**Reverse Jeopardy** What do you do if somebody wants to appeal?
Indicate what your process is if someone indicates they want to submit an appeal. Appeals can be initiated verbally or in writing.
100
This "hotline" is a confidential line and will not release your name when you make a report.
What is the Ethics hotline?
100
30 calendar days from the date of receipt of the appeal by the organization.
How many days does the organization have to complete a standard appeal?
100
All new employees receive this.
What is orientation or training?
100
Close the door to the home office when working in it and others are in the house; hardcopy documents are locked and/or shredded; computer is secured with locking device or placed in locked cabinet when not in use; passwords required to logon to computer and applications.
How do you maintain confidentiality while working from home?
200
Clinical staff: cases that meet medical necessity based on applicable evidence based criteria or per the benefit document. Non-clinical staff: can review administrative cases or cases that do not require evaluation or interpretation of clinical information.
What types of cases that can be approved?
200
After 3 attempts.
What is the number of attempts before you are locked out of the computer?
200
Within 30 calendar days from time of request. Indicate if you do not do retrospective reviews.
How long do you have to make a retrospective determination?
200
Trainings on P&P's, regulatory, HIPPA, URAC, systems/applications, processes, etc.
What are the trainings included in orientation?
200
***Reverse Jeopardy** Tell me about your office space?
Explain where your home office is located; who has access to it. Indicate if there is a door, shredder for papers, etc. *per our telecommuter policy - office needs to be in a locked room, comp away from windows, no fax/printer, etc.
300
Clinical staff: can take all information related to the case in order to make a determination. Non-clinical staff: can take demographic info, ICD/CPT codes provided by the caller, structured clinical information.
What is the different types of information that can be obtained?
300
every 3-6 months depending on the application/ system.
What is the frequency of required password changes?
300
urgent pre-service - 72hrs non-urgent pre-service - 15 calendar days urgent concurrent - 24hrs non-urgent concurrent - 72hrs retrospective - 30 calendar days
What are the timeframes for making determinations?
300
**Reverse Jeopardy** Do you have a training or orientation manual?
Indicate the training material is online on the Training Portal.
300
**Reverse Jeopardy** Do other's have access to your office, if so, how is information secure?
Explain if others have access to your home office area and how you secure your computer and documents. *Locking cable, password protected computer, etc.**
400
Letters are written in plain, easy to understand language. Verbal communication is in simple, easy to understand sentences.
How do we communicate with members verbally or in writing?
400
Working on a case in which you may know the person such as a family member, friend, neighbor, or coworker. Outside employment that hinders your work with UHG. Doing business with companies for which a family member works. Having family members report to you.
What are examples of conflict of interest?
400
Within one business day on other requests not tied to a specific standard TAT.
When do you respond to messages left by providers?
400
**Reverse Jeopardy** When was your last privacy training?
Privacy and confidentiality training is done annually. *this included training regarding the increased penalty for breach of privacy (HITECH).
400
**Reverse Jeopardy** What keeps family members from accessing hard copy information?
Explain how this is avoided. e.g. indicate if all of your information is electronic; if you do have hard copy information explain where it is stored or how it is destroyed. ** we do not have hard copy info - no printer, no fax, etc.**
500
"peer clinical reviewer"
What is our medical director?
500
Report it to the Manager, Business Privacy Contact, Compliance HelpCenter. Contact facility/MD and ask them to shred.
What is process if you faxed PHI to a wrong physician or facility?
500
15 calendar days provided the organization determines that an extension is necessary because of matters beyond the control of the organization and the member is notified of the extension and is given at least 45 days to provide the information.
How many days can an extension be given for non-urgent prospective review requests?
500
URAC standards is part of THIS
What is annual training?
500
VPN and RSA token
How do we access the internet from home?
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