Pathway Picker
Maria’s Housing Transition Supports request includes a complete PAR, Unified Housing Assessment Tool, Housing Support Plan, and Housing Crisis Plan. The requested service matches her documented need, and no RFI is active. What pathway should Review consider?
Review should consider Administrative Approval if all program and workflow requirements are met.
Action Steps
Confirm eligibility, service match, required documents, no active RFI, correct line item, and aligned Review Summary, rationale, outcome fields, and notice before finalizing.
Approval is a pathway supported by the full record, not just a good feeling about the case.
Tanya’s deposit request includes all required documentation, but the reviewer wants “extra background” that would not change the determination. Should staff issue an RFI?
No. Staff should not issue an RFI for information that is not needed to make the determination.
Action Steps
Ask whether the information would change the pathway. If not, proceed with the appropriate review steps using the documentation already in the record.
Remember
Ask only for what you need.
The Intake note says the PAR was received on one date, but the authorization shell uses a different PAR receipt date. What should staff do?
Staff should stop and reconcile the date discrepancy before proceeding.
Action Steps
Verify the correct PAR receipt date, update the record if allowed, document corrections as appropriate, and ensure turnaround time tracking aligns.
Remember
Dates drive timing, so they must be accurate.
What should a strong Review Note explain?
It should explain what was requested, what was reviewed, what decision was made, and why.
Action Steps
Reference the request, relied-upon documents, service fit, pathway, and rationale clearly.
Remember
Good notes answer tomorrow’s questions today.
The notice is correct, but the User Notes section includes the wrong approved amount. What should staff do?
Staff should correct the User Notes before sending.
Action Steps
Compare User Notes to the determination fields, approved amount, line item, Review Summary, and Claims Information if applicable.
Remember
User Notes are part of notice integrity.
Tanya’s deposit request has an identified unit and itemized amount, but prior deposit history is unclear. What pathway fits best?
Do not approve yet. Staff should stop and verify prior utilization or escalate if the utilization history cannot be confirmed.
Action Steps
Check alerts, prior authorizations, claims/payment indicators if available, notes, and documentation. If history remains unclear, document the concern and escalate before approving.
Remember
Unclear deposit history is a stop point.
The Housing Support Plan is missing from Maria’s request, and it is needed to support service review. Is this an RFI situation?
Yes. If the missing document is required and correctable, staff should issue the appropriate RFI.
Action Steps
Confirm the document is not already uploaded and linked, issue the correct RFI letter, document what is missing, and do not determine while the RFI is active.
Remember
Missing required information usually means RFI before decision.
The authorization line item says Housing Sustainment, but the Review Summary explains Housing Transition Supports. What is the risk?
The record is internally inconsistent and may not support the determination or notice.
Action Steps
Stop, identify whether the line item or documentation is incorrect, correct or escalate the issue, and do not finalize until the service, summary, rationale, and notice align.
Remember
One case should not tell two different stories.
A Review Note says, “Approved per documentation.” What is missing?
It does not explain what documentation was reviewed or why approval was appropriate.
Action Steps
Update the note to identify the documents reviewed, summarize the documented need, explain service fit, and connect the facts to the approval.
Remember
Clear documentation protects everyone.
Should staff preview a notice before sending it and if so why?
Yes. Notices should be previewed before sending.
Action Steps
Review the notice for correct Member, service, dates, rationale, recipients, enclosures, User Notes, and appeal language when applicable.
Remember
Stop and preview before sending.
A request appears to meet criteria, but the authorization shell was built under the wrong service/procedure code. Can Review approve the case and ask Intake to fix it later?
No. The record must be corrected before determination. The authorization shell, line item, service, procedure code, and documentation must align.
Action Steps
Stop, document the issue if needed, return for correction or escalate based on workflow, and do not finalize the determination until the TruCare record is accurate.
Remember
The correct pathway requires a correct TruCare record.
James’ Sustainment request states he is housed, but there is no move-in date, housing location, or tenancy risk. What should Review consider?
Review should consider whether an RFI is needed because documentation does not clearly support Sustainment.
Action Steps
Check all uploaded and linked documents, identify the missing sustainment details, request only the missing information needed, and pause determination while RFI is active.
Remember
Sustainment requires documentation showing housing is secured and support is needed.
A reviewer notices the “Authorized By” field was not completed because it did not have a red asterisk. Is that acceptable?
No. If the workflow requires the field, staff must complete it even if the system does not visually flag it.
Action Steps
Complete the required field, confirm other non-obvious required fields, and use the HSS checklist rather than relying only on red asterisks.
Remember
System prompts do not replace workflow requirements.
A denial rationale says, “Not enough information,” but the record does not show that an RFI was considered or issued. What is the concern?
The denial may not be defensible if the missing information was correctable and RFI was appropriate.
Action Steps
Review whether RFI should have been issued, document the basis for the pathway, and escalate if denial versus RFI is unclear.
Remember
The pathway must be as defensible as the decision.
A provider was supposed to be called before notice generation, but the call was not completed or documented. What should Review do?
Review should complete and document the required communication step before generating or sending the notice, if required by workflow.
Action Steps
Call the CBO/provider, document attempt and outcome in TruCare, and ensure the communication does not conflict with the official notice.
Remember
Communication should support the record, not sit outside it.
A provider submits missing information after an RFI, but the response only answers part of the request. The remaining missing information could affect the determination. What pathway should Review consider?
Review should not proceed to determination until the missing information issue is resolved according to workflow. A second RFI, denial based on available information, or escalation may be appropriate depending on timing and requirements.
Action Steps
Document what was received, identify what remains missing, confirm RFI timing, determine whether a second RFI is appropriate, and ensure no active RFI remains before determination.
Remember
Partial response does not automatically mean ready for decision.
A provider responds to an RFI by sending a document through email, but it has not been uploaded or linked in TruCare. Can Review use it to decide?
No. The document must be uploaded and linked in TruCare before it is relied upon.
Action Steps
Upload the response, rename it if possible, link it to the authorization and applicable line item, document the response, and then continue review.
Remember
If you rely on it, upload it and link it.
Tanya’s approved deposit amount in the determination field is $1,500, but the Claims Information note says $1,800. What should staff do?
Staff should stop and correct the inconsistency before final action.
Action Steps
Compare the approved amount, itemized support, Claims Information, determination fields, and notice. Correct the record so all amounts match.
Remember
Deposit payment support must match the approved authorization.
Tanya’s deposit approval note says the request is approved, but does not mention utilization check, Fair Market Rent review, payee, or Claims Information. What is the issue?
The note does not document key deposit controls, which creates audit and payment risk.
Action Steps
Update the note to include prior utilization check results, Fair Market Rent/cost review, approved amount, payee, and Claims Information alignment.
Remember
Deposit decisions need deposit-specific documentation.
Everything appears ready, but the letter preview shows the wrong service line and dates. What should staff do?
Do not send the notice. Correct the underlying data or escalate if the system is generating the wrong information.
Action Steps
Check the authorization line item, dates, service, determination fields, and template. Escalate if the issue cannot be corrected safely.
Remember
A wrong notice is a stop point.
A case has enough documentation for partial approval but also appears to reduce or deny part of the provider’s request. What should staff do before using a standard Admin Approval or Admin Denial pathway?
Staff should stop and escalate if partial approval, reduction, suspension, termination, or adverse decision handling may apply and the pathway is not clearly authorized.
Action Steps
Identify what is being approved versus not approved, compare requested and supported services/units, document the issue, and escalate to the appropriate owner before notice activity.
Remember
When the action may affect rights or appeal language, do not guess the pathway.
An RFI is still active, but Review believes the available documentation is enough to deny. Can Review finalize denial while the RFI is active?
No. Staff should not make a determination while an applicable RFI remains active.
Action Steps
Confirm RFI status and timing, close or resolve the RFI according to workflow before determination, and document the final basis for the pathway.
Remember
No determinations while RFI is active.
Before sending the notice, Review sees that the note, outcome field, letter, and line item do not all match. What is the correct launch-ready response?
Do not send the notice. Stop and correct the TruCare record before finalizing.
Action Steps
Reconcile the line item, determination field, Review Summary, rationale, User Notes, enclosures, recipients, and notice template before sending.
Remember
Notice readiness depends on data integrity.
Robert’s rural case is escalated, but the note only says, “Sent to Kevin.” What should be improved?
The note should explain why escalation was needed and what decision or guidance is being requested.
Action Steps
Document the issue, why it affects the pathway, known facts, documents reviewed, and the specific guidance needed.
Remember
Escalation notes should make the question clear.
Review determines that an RFI is needed before a decision can be made. In addition to the appropriate Missing Information letter, what other letter may need to be sent when the RFI extends the standard authorization timeframe?
The PA Notice of Std Auth Timeframe Ext_NV may need to be sent when the RFI extends the standard authorization timeframe, if required by workflow.
Action Steps
Staff should issue the correct RFI letter, determine whether the standard authorization timeframe is impacted, send the timeframe extension notice when required, document the action in TruCare, and confirm the RFI and extension activity align with the authorization timeline.
Remember
An RFI can affect turnaround time, so staff must consider whether an extension notice is also required.