CRITERIAS & POLICIES
What is the highest level of the hierarchy?
Federal Guidelines
HOW OFTEN DO YOU EMAIL YOUR PRODUCTIVITY TRACKERS
DAILY
______ is our Senior Manager
Teresa
JOB AIDS, CHEAT SHEETS, TEMPLATES, & MEETING MINUTES CAN BE FOUND HERE
UTILIZATION MANAGEMENT TEAM SITE
Transgender services require this type of review
WPATH
This IQ subset is intended to be used when a patient's condition, symptom, or finding is not included in a condition-specific subset.
General Medical
Expedited cases require an RN to de-expedite. True or False?
True
COC job aide needs
nurse feedback
Self-service, My Tickets, Access Approvals, and Ask Max can be found in
Request Central
Commercial LOB: Service rendered by non-par and no criteria is found, what is used to support review?
EOC
This association promotes the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People
WPATH
A valid member appeal requires this
A valid denial on file
_______ is our Senior Director
Susie A. Castilleja
By what hour do we have to clock out for lunch?
Before the fifth hour of the shift
Patient fell from a 4 story-balcony & on mechanical vent. On Day 21 the patient went back to the OR for the 3rd time, what subset and episode day should be used?
General Surgical; Episode Day 1
Resources we use to support investigational/experimental services
Hayes
How many attempts are required to obtain additional clinical information (RFI) before sending the case on to the MD for review?
Only one is required, two is considered a courtesy
We send Medicaid Peds cases to _______
Dr. Nam
System applications can be found here
Centene Connect
If a case is denied under general medical in IQ, what criteria do you review on appeal?
IQ General Medical
POLICY NUMBER FOR PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY SERVICES
CP.MP.49
Case status reports are sent how many times a day?
Once!
You have __ hr(s) to call in before the start of your shift
1 hour
Meal penalty waiver link (Meal Break Acknowledgment) must be selected by the employee and a secondary acknowledgment by the manager for authorization is required in what time keeping system?
myPay
Why do the MDs want you to contact them if you have any questions re: your clinical review?