SDRs
What does the acronym "SDR" stand for?
SDR = Service Determination Request
How often is the IDT's plan of care on a participant re-evaluated?
Plan of care is re-evaluated on at least a semi-annual basis (every 180 days).
How can a staff member receive a grievance from a participant?
A grievance can be received from a participant either verbally or in writing?
Where can you submit RADs for UM review?
You can submit RADs using the RAD Submission Form that is pinned in both Care Team chats and the Q/C Q&A Teams chat.
Where can you submit Quality or Compliance related questions?
You can submit questions via email to our Compliance distribution list at PACE-Compliance-DL@multicare.org or our PACE Quality & Compliance Q&A Teams chat. Or attend our Q/C/PI/UM Office Hours! :)
Where can you submit SDRs to the Quality/Compliance Department?
You can submit SDRs using the SDR Submission Form that is pinned in both Care Team chats and the Q/C Q&A Teams chat.
Where can you submit Agenda Requests for the IDT meeting agendas?
You can send agenda requests to the participant's care team email distribution list, (PACEIDT_Nisqually-DL@multicare.org or PACEIDT_Columbia-DL@multicare.org) with “Agenda Request” in the subject line.
Where are grievances submitted?
Grievances are submitted into HeRO using the Multiple Issue Feedback option
Where can you find Skilled Nursing Facility UM Reviews?
In the care team specific channels designated for UM reviews (1_Col SNF_IPR Auths & 1_Nisq SNF_IPR Auths).
Where can you submit a performance improvement idea to the Quality, Compliance, Safety and Performance Improvement Committee (QCSPIC)?
Performance improvement ideas can be submitted via the Performance Improvement Project Request Form, pinned in the Quality and Compliance Q&A Teams chat.
True or False: The IDT member who provides oral notification of approval/denial to the participant should document the oral notification in Epic.
False, the Quality/Compliance Coordinator will document the oral notification of the IDT’s decision in their template.
Which three disciplines at minimum are required to complete the following assessments: semi-annual and change of condition?
Three required disciplines for semi-annual and change of condition assessments are PCP, RN, and MSW.
How soon should PACE staff members submit a grievance after receiving one from a participant?
Grievances should be submitted within three days of receipt whenever possible.
Where can you find Inpatient Hospitalization and ED Visit UM Reviews?
In the participant's chart in Epic as a Care Coordination phone visit.
To be eligible for PACE, someone must live within the service areas of the PACE organization. How are these service areas geographically defined?
These geographical areas are zip codes (PNW PACE is currently accepting enrollees in Pierce County and southern King County).
What are the three types of request that define an SDR? (A request to….)
The request to initiate, modify, or continue a discontinued/reduced service.
What is the timeframe for the IDT to develop a comprehensive plan of care for a new enrollee?
Within thirty (30) days of enrollment
What is the CMS required timeframe for resolution of grievances?
Grievances must be resolved within 30 days of receipt.
What does the acronym "RAD" stand for?
RAD = Resource Allocation Determination.
What is the age of eligibility for PACE programs?
PACE participants must be 55 years of age or older.
The IDT member performing an in-person assessment for an SDR must evaluate whether the requested service is necessary to meet which domains of medical necessity? (4 domains)
Medical, Physical, Emotional, and Social
What is the maximum timeframe for the IDT to complete in-person assessments and complete (review and revise) the care plan for unscheduled reassessments (change in condition)?
The IDT must complete assessment and care planning for unscheduled reassessments within 14 calendar days (two weeks).
What is the difference between a Grievance and a Complaint?
A concern can be treated as a complaint when: The participant does NOT want to be part of the resolution, they want to remain anonymous, or they don’t want a follow‑up about the outcome. A concern becomes a grievance when: the participant wants to be involved in the resolution, they do want to know the outcome, or they express dissatisfaction and want it formally addressed.
What are the exact timeframes for UM review of a RAD? (Routine, Urgent, Emergent)
Routine - within 30 days, Urgent - within one week, Emergent - within 24- 48 hours.
After an individual has exhausted the internal process for an appeal, they have the right to an external appeal through one of which two agencies?
What is Medicare or Medicaid?