What the What If?!
A bold claim! The provider is refusing to send us records because they have unpaid claims from Elevance. A tough situation, but you know to do this:
Explain that while we're sorry, we can't help them, and they'll have to call the number from their latest claim statement.
We can Escalate after a few attempts if they still refuse to work with us.
Don't let this get too high! This measure has one of the widest range of providers we can pursue, we can even request from a dentist office! No wonder it's first in the measure instruction sheet...
BPD or CBP
Who?? The provider listed has never been at the site and the medical records manager has never heard of that patient! You find the doctor in another town and practice so here's what you do...
Unlink the provider and link them to their correct site, make sure to not leave them hanging out in the unlinked provider section!
Where we find the members we're chasing, also where we fax, and add site action notes
The Requests Tab!
What a tangled web... the office tells you that they don't have time to verify all 10 providers or give you the medical records fax, they think they're updated on Healthgrades or ZocDoc maybe. That should work, or will it?
No, we can only use verifications from an official company website. If they don't have a company website we'll have to call back at a better time
Oh no, the provider passed away last year! Looks like the office still has the members records though, what next....
Since the records are with the site and the provider left within the year we should verify the provider and send the request, just add the information about the provider to your site action note.
Its a record request! This measure request is most commonly sent to OB/GYN providers and the request letter will include the delivery date
The PPC or Prenatal and Postpartum Care measure
Huh! You have 5 sites in your bucket with the same practice name and phone number but different addresses, as much as they would love talking to you it might be better to ask about this instead-
Ask if they process medical records at a central location so you can Merge the 5 sites into one
Take Action! This is where we can review all of our past calls and fax attempts, helpful when we need to call sites back
The Site Actions Tab
You want it when?! The packet with measure requests providers return records within this timeframe
5 Business days initially, within 3 days in the final weeks
Pay up! The office wanted us to pre-pay for medical records and sent us an invoice, we paid the invoice 15 days ago and it was sent back to the Phone Team but the office still won't sent those records. What to do?
Escalate it by adding ESC_ to the front of the existing invoice teams code of PAID_date
Lets get physical! This is the only measure that asks for a BMI chart and nutrition counseling documentation.
The WCC, or Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents measure
You go to call your site and the phone number is disconnected. You check TMV and, that's weird; you can't even find a claim for that member and provider. Good thing you know to do this-
Send the chase to Need Auth since no claims exist for this member and measure
The provider gives you the main fax number and a direct MR fax number for the office manager, awesome! I'll enter the the main fax number under the address and phone number, and the MR fax and contact person here-
As the primary Contact in the Site Info tab
The provider wants the packet emailed, don't forget to include this is the subject line when sending the packet
Secure
Test emails don't contain PHI so won't need to be marked secure but the packet contains member names and DOB, and should be protected
To send or not to send? The office tells you that they don't want to be bothered with us faxing over the packet, they would rather that we just send it directly to their copy service ScanStat.
Sorry, we cannot send faxes over to any indirect/non-contracted copy services; we'll have to send the request to the office so they can forward over the MRR.
Better with age! While we can request from other providers, this measure is often sent to nursing homes, skilled nursing or hospice facilities, and home health agencies.
The COA or Care of Older Adults measure
As you're calling your site you discover that they don't have any record of one of the providers, or their attached member. Google and TMV turn up another location but no working phone number, we can't just leave them on the site, what to do...
We can't unlink this provider since we don't have a new location for them, and we never unlink unless we have a new home for that provider and member.
We'll have to send them to Need Auth
Your provider tab doesn't list the name of a doctor or nurse, it just has the name of the location. That's ok, it just means I have to verify this instead
If the provider is listed as a location name we should verify that the member is at that practice, either over the phone or by checking claims for that location in TMV
Who ya gonna call(or ping)?! Your Cotiviti password isn't working and you need a reset, who are you reaching out to?
You training lead or Manager
Remember, IT can't help with Cotiviti issues or resets and we NEVER reach out to the Cotiviti contact
Just the fax? Not for me! The office would rather you send them the medical record request via email instead, you verified the providers and the email address (twice) and now what?
Send the office a test email to make sure the email address is correct and drop the request packet in the "Needs Password Protect" folder so you can send the protected packet when you get a response.
Bonus 25 points if you remembered to tell them the password over the phone!
In Transit? Requests for this measure will include any admin or discharge dates so providers can send us the progress or consultation notes that lead up to, or follow those dates.
the TRC, Transitions of Care, measure
The office and provider you're calling ends up being a social worker who never sees patients! That's weird, good thing you know what to do next...
Send them to Need Auth since this would be an incorrect specialty
In your site list (bucket) we know we should be sorting from biggest to smallest, but which request column will we be sorting? hint, its one of the ones with the # sign
Workable request! Remember we only want to work the workable requests; a site can have requests that are open but not necessarily workable
You sent your password protected packet in an email to the provider but now they're ignoring your emails and calls, how rude! After 3 more unsuccessful attempts you update the Area Code to this, and add this Site Action selection so you can add your explanation
ESC_EMAIL with the Site Action ESC Sent