SOPs
What is the turnaround time for a routine case?
15 calendar days
15
Tells you if the requested service needs precertification/ prior authorization
Aerial Benefit Plan (Ben Plan)
Member Details > Enrollment > Benefits Link
Name 3 types of Aerial Notes
1. Claim Note
2. Member Note
3. Case Note
Cases lacking clinical after 2 documented attempts to request for clinical can be _____________
Administratively Denied
Check Aerial Policy Start/End Date
P2P reviews must be requested within ________ calendar days
21
Houses fax archives of clinicals
Alchemy
Provide 2 main clinical criteria guideline sources per the Clinical Guideline Hierarchy (cite which ones you will refer to in the correct order).
1. Internal
> UHC Medical/Drug Policy or CDGs
2. External
> InterQual
> NCCN (for chemotherapy/imaging with cancer as primary dx)
> FDA (if no UHC drug policy available)
> LCD (for DMEs)
Therapy treatment beyond 12 weeks for same condition without significant progress/complications and possible maintenance therapy should be _______________.
Presented to MD rounds
Source: Home Health and Therapy Visits SOP
The medical director will reach out to the provider requesting for P2P within _____ business day/s
1
A request that is deemed life threatening if not treated within 72 hours is considered ______.
Urgent
Houses group folders and allows you to locate documents containing covered/excluded services
ISTREAM
You receive a faxed clinical that says URGENT. What will you do with the task?
Change task priority to URGENT.
What will you do for requested codes that will not be used as part of the requested service?
1. Edit Request
2. Void Service
3. Enter Claim note
How will you handle Air Ambulance requests?
Send MD for secondary review
What tasks must be done for Medical Director referrals?
1. Create task to MD (physician advisor/medical director)
2. Edit task assign to yourself (physician advisor/medical director), keep it assigned to yourself
Gives you an overview of covered/excluded benefits
HPBD (Health Plan Database)
2
It is safe to render an administrative denial if it has been ___ days from the date of intake notification
13
Notification to providers for denied cases must be done via __________
Live Call/Voicemail.
Never fax a denial.
NCCN is appropriate to be used for case reviews of what type of oncology-related requests? (provide at least 1)
It contains authoritative, scientifically derived information designed to support decision-making about the appropriate use of drugs and biologics in patients with cancer.
NCCN Compendium
Give 2 next steps after entering a decision in Aerial (Approve/Deny/Void)
Any 2 of the following:
- Ensure letters are sent c/o letter team
- enter case note
- close out task
- for OP only: check if case was closed
- for IP only: check if new task to IP RN was created
Request for IP stay for a patient who failed oral antibiotic therapy.
Dx: Cellulitis
CPT: L02.612 Cutaneous abscess of left foot
How many days will you approve?
1 IP day per Intake Initial Screening Tool (Cellulitis)