Clinical
When is the consent absolutely necessary to fill out? (THINK ALWAYS)
Upon Enrollment
When is a plan of care due?
60 days of enrollment and annually
Name the forms you mail when dis enrolling a member?
Withdrawal Consent form 5058
Notice of determination 5235
Letter
What are the mandatory assessments?
Health Risk Assessments
Social Determinants of Health
Risky Behavioral
HML
Do you place a member that went to Mexico for 29 days in excluded setting?
No
Do you bill for a member who died?
No
How often does a care plan get updated? (Best practice)
Monthly
How long do we have to wait to close a case, after the 5235 was mailed?
10 days
How often should the assessments be completed?
First 60 days of enrollment then once a year and/or significant change
How long can a member stay in excluded settings?
6 months
Writer called EC who confirmed member's contact information was incorrect. EC provided member's new number, is that a billable note?
Yes
Which domain would SNAP be considered?
Social
What is the difference between opt out and graduation?
Member goals are completed is a graduation, if not completed then opt out
Name the criteria's that considers a member to be high acuity?
Homelessness, Incarcerated, IP mental health, IP PH, IP SUD, HIV
How soon/often should you call a member if the member has been hospitalized?
24-48 hours of hospitalization then 7 day upon discharge then 30 day upon discharge
What must be completed if a member states they are suicidal? And where should it be documented?
Crisis Plan and a copy in document management
What must be added into your care plan even if it was not included in the initial care plan? *HINT (3)*
High Utilizer, transitional, gaps in care
Whom must be called when closing a case? Besides member?
MCO/PCP
What is the date released for the new consent form?
03/18
What must be completed before you can transfer a case? (In house)
All assessments completed, care plan updated, consents on file, member must be aware, all notes finalized
Which note type do you use for a case conference with an external provider?
Care Coordination (Collateral service provider)
Name the 5 main elements in a care plan?
Goals, Time frames, Interventions, Barriers, Strengths
Name 5 reasons member's can be dis enrolled? Excluding Diligent Search and Member opt out.
Graduation, move out of state, MLTC, Expired, Transfer, inactive medicaid, exception codes, inpatient facility...etc
What is additional primary documents needed for HIV members?
5032-DOH-HIV consent, viral load, SD4
Name 6 activities in order to complete a diligent search status change?
Call Member, EC, Drive By, MCO, plus two more activities