Where we refer a member when a behavioral health issue is noted and in need of care management services
What is Cenpatico
200
Electronic fax management/storage/system
What is RightFax or FileNet
200
PA
What is a prior authorization
200
Member specific provider contact information
What is member menu bar/member information/contact summary
200
Urgent Pre-Service; expedited prior authorization turn around time
What is within 24 hours of the request for service
200
The process in which a provider can request reconsideration related to a previous decision in which an an adverse determination was made.
What is an appeal or peer-to-peer
300
Customer Relations Management/where we enter information when eligibilty data is different in TruCare then in Amisys
What is CRM
300
P2P or PTP
What is a peer-to-peer
300
Approved services letter, notice of action letter etc
What is member authorization summary; notification; correspondence summary
300
Nationally recognized criteria set used to determine medical necessity
What is InterQual
300
Not for profit organization dedicated to improve health care quality via working with organizations who must pass a rigorous comprehensive review and must report their performance on an annual basis
What is NCQA
400
Provider information data base management
What is Portico
400
LOC
What is level of care
400
Living will; DPOA
What is documentation; document summary
400
What a nurse will do with an authorization when IQ or other medical necessity criteria is not met and request for additional information has already been completed
What is forwarding authorization for secondary review
400
24 hour nurse triage
What is Nursewise
500
Mother-ship, member eligibility, I pay claims
What is Amisys
500
CCR
Concurrent Review
500
InterQual review; medical review notes; rationale
What is line item summary; clinical review
500
Urgent CCR, member in the process of receiving ongoing care, turn around time
What is within 1 business day of obtaining all clinical information, not to exceed 14 calendar days or per HP specific policy
500
Utilization management decisions are made in a timely manner to accommodate the clinical urgency of the situation and to minimize any disruption in the provision of health care. Established timelines are in place for practitioners to notify the plan of a service request and for the health plan to make UM decisions and subsequent notifications to the member and practitioner