The UM 411
Where to find what type of UM episode is displayed in JIVA.
What is beside the Member Overview tab?
Importance of UM-CM collaboration.
What is to provide updates to members and family?
Timeframe that clinicals have to be received to be relevant for assessing member approval for facility.
What is 24 hours?
UM uses this to determine approval for members going to Rehab. or SNF.
What are Hit Lists?
UM nurses cannot deny a request. This is who the request goes to if the UM nurse cannot get the criteria to meet.
What is the PAR (Physician Advisor Review)?
Represents IP request to be reviewed.
What is a Stay Request?
Most important reasons for CM involvement from UM standpoint.
What is discharge planning, SW involvement, caregiver education?
Timeframe for expedited reviews to be assessed.
What is within 3 days of receipt date?
Prolonged admissions need to be communicated through this by the CM, if UM has not communicated with the PAR.
What is a PR (Physician Review {by our Medical Director})?
This is a necessary component of the UM note to the PAR.
What is a brief member clinical summary?
Represents OP request to be reviewed.
What is Service Request?
Resources CM's can prepare to provide members who are in the process of getting approval by UM?
What is transportation, caregiver assistance, disease management education, etc.? (Use nursing judgement)
Standard review time.
What is 7 calendar days of receipt?
BCBSAL review request process.
What is?:Blue Cross and Blue Shield of Alabama (BCBSAL) must have a process in place to accept coverage requests 24 hours a day, 7 days a week (including holidays) and to notify members of coverage decisions within 72 hours of receipt and 17 days if extension is applied. For Part B Drugs, the decision will be made within 24 hours, and no extension will be taken.
True or False: The same PAR that originally reviewed the member's request can review it for the second time.
What is false? It has to be a different PAR for each review.
Where you look to see approval dates and UM nurse information.
What is the note section?
Difference between precert., concurrent, and retrospective reviews.
What is?:
When a Medicare health plan has approved coverage of an enrollee’s admission to a SNF, the enrollee must receive a Notice of Medicare Non-Coverage (NOMNC) within this time frame.
What is at least two calendar days in advance of the services ending?
Questions to Ask r/t Hospital Stays within a SNF Stay.
What is?:
First, is this the same SNF they were in prior to admit
Second, was the member gone less than 3 nights?
Third, is the hospital admit an inpt or outpt admit?
What happens when IQ is not met (process).
What is?:
Refer to the PAR; PAR completes the determination; Assigned nurse reviewer receives an alert, "Physician determination has been made"; Nurse reviewer reviews PAR clinical rationale and notifies the provider; determines appropriate correspondence
System that is used to determine approval for medical necessity of hospitalizations.
What is Interqual (IQ)?
The Health and Clinical Engagement UM operational units.
What is?:
Expectations of time regarding patient participation at alternate levels of care (ALOC).
What is?:
When reviewing LTAC referrals, the expectations are generally that the member will be in the facility for at least 24 days.
When reviewing AR referrals, the general expectations are that the member can participate in at least 3 hours of combined therapy daily.
When reviewing SNF referrals, the general expectations are that the member can participate in approximately 1.5 hours of combined therapy daily or have some other skill that requires a nurse in an inpatient setting to provide.
Process of expedited request downgraded to standard.
What is?:
Process for submitting PAR.
What is?: Write note with clinical rationale for why the request does not meet criteria (Insert PAR request template (this is a template within Jiva Notes). Use note type Clinical Summary). Start at Clinical Summary, under PAR Request.