MEDICAL POLICIES
Where to look up Medical Policies.
What is Knowledge Library?
This tells you whether the case is for a Med Nec No or a Med Nec Yes policy.
What is the Medical Necessity Indicator in the Left-Hand Navigation Panel.
Where to continue a case Review if there is no applicable Medical Policy and the case is Med Nec Yes.
What is InterQual?
What is Tab 1 Notification Tab?
This is offered to a Provider when a Medical Director has made an Adverse Determination in a case.
What is a P2P?
These can be accessed by the general public by performing a Search in Google.
What are the UHC/Optum Medical Policies?
This Tab is where you would find any specific clinical information that the Provider gave to Intake in a phone call.
What is the Notes Tab?
Where InterQual criteria is documented after a case is determined.
What is Doc360 - Clinical Documents?
The email address to give Providers who need to send in clear, color photographs.
What is CCR@uhc.com?
This is the first source we go to for specific Templates/Macros for a case.
What is Template Hub?
The name of the dark blue button in KL that can be used to look up Medical Policies.
1. The Provider Network Status (INN or OON) and
2. The correctness of the Provider Roles
What is one of the two things you definitely should be looking for in the Provider Tab?
The words you are looking for in InterQual that mean you can Clinically Approve a case.
What is "Criteria Met"?
Name of the Medical Policy used to determine a LOC Review.
What is Elective Inpatient Services?
A SOS (Site of Service) Review.
What type of Review will be done on an ASO, Med Nec YES case for a Hysterectomy if the ASO Buy Up Indicator on the left-hand navigation panel is YES and Hysterectomy is listed as a Buy Up Indicator?
A second way to access Service Codes and Medical Policies in KL.
What is the "CODER" button in the Services Tab?
HSR Tab where you can send a fax from.
What is Tab 11 Review Requests?
The two times InterQual is used in a Clinical Review (Level 2 Review).
What is
1. When the case is a Med Nec Yes and the Medical Policy instructs you to go to InterQual,
2. When the case is a Med Nec Yes and there is no relatable Medical Policy.
A document you can refer to if you need to call a Provider and ask that they switch from an Inpatient request to an Outpatient request.
What is the Inpatient Conversion Job Aid?
This is how most written Notices of Approval Determination are sent.
What is the autobot?
The section you first go to in a Medical Policy to determine if a case meets Medical Necessity or not.
What is Coverage Rationale?
These are the entities involved in a case that will get a written Notice of Determination for a case.
What are
1. the Member,
2. all the Providers listed in the case?
A LOC (Level of Care) Review.
What type of Review must be completed on all Inpatient cases?
This is where you can see a DTQ (Decision Tree Questionnaire) if one has been completed.
What is Doc360, drop down Clinical Documents?
This is the situation in which the Letter Team will send both the Approval portion AND the Denial portion of a Notice of Determination.
What is when the Determination is a CLINICAL (not Administrative) Split Determination?
This service request can be Approved for 6 months on the Initial Request and 12 months for Subsequent Requests.
What is CGM (Continuous Glucose Monitor) and supplies?
Tab where you would find the TTAP information for a case (if it ran through TTAP).
What is Tab 7 Notes (or Tab 13 History)?
The document that tells us the steps we follow if asked to release InterQual Criteria for Clinical Review to a Provider.
What is the "InterQual Requirements" SOP?
Where you can look to see if an Inpatient Code requires a full LOC Review or if it is a code that can be Approved without a LOC Review.
What is the "LOC Code List" in KL?
Where you find a printed version of the CCR Clinical Review Hierarchy.
What is the SOP "Applying Benefit Plan and Review Criteria"?