CRITERIAS & POLICIES
This subset is intended to be used when a patient's condition, symptom, or finding is not included in a condition-specific subset.
General Medical
HOW OFTEN DO YOU EMAIL YOUR PRODUCTIVITY TRACKERS
DAILY
DMHC CASES HAVE A _ TAT
2-DAY TAT
JOB AIDS, CHEAT SHEETS, TEMPLATES, & MEETING MINUTES CAN BE FOUND HERE
UTILIZATION MANAGEMENT TEAM SITE
Transgender services require this type of review
WPATH & MD
THIS SUBSET ALWAYS REQUIRES AN MD REVIEW REGARDLESS IF IT MEETS OR NOT
SEPSIS
THIS IS WHERE YOU LOOK FOR AN < 21 APPROVED, PENDING, OR DENIED SAR COVERING THE SERVICE, PROVIDER, AND DATES ON THE CLAIM
PEDI WEBSITE
Post service group has a courtesy of _ hrs to respond to clarifications
24 hrs
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
Any day during the first 7 days of the hospitalization that meets for Episode Day 1 at any level of care (LOC) within the appropriate InterQual Subset, means the entire inpatient stay can be approved.
DRG
_______ is our Senior Director
Susie A. Castilleja
Allows you to determine who is financially responsible for authorized services Health Net (assigned Medical Group ( and associated Hospital (Shared/
PSAS
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 and/or NCBI
WHAT LEVEL OF CARE (LOC) DO WE NOT REVIEW FOR?
WHAT IS OBSERVATION LOC
You have __ hr(s) to call in before the start of your shift
1 hour
System applications can be found here
Centene Connect
What criteria do you use for trauma?
American Committee of Surgeons (ACS) trauma criteria as well as local county guidelines
POLICY NUMBER FOR PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY SERVICES
CP.MP.49
There are services and items that have limits, once limits have exceeded, medical review is required. What type of review is this?
Max Benefit Reviews
Cases over $__ MCAL or $__ COMMERCIAL, require physician review
$75k MCAL & $125k COMMERCIAL
YOU CAN LOCATE EOCS IN THESE (2) PORTALS
Omni & OCOE
250 kg patient is ready for DC to subacute; A possible barrier to discharge would be
Placement due to need of Bariatric Bed