Shell Build & Intake
Shell built, but documents referenced in notes are not linked. Intake note says “Lease and invoice reviewed,” but neither document is linked in TruCare. What went wrong?
Relied-upon documents must be uploaded and linked before routing or progression.
Record clearly supports approval, but reviewer issues RFI anyway. UHAT and housing support plan clearly support service, but reviewer asks for “any additional documentation.”
RFI must not be used when approval pathway is already supported.
RFI message: “Send anything else you have for this request.”
RFI must be necessary, relevant, and specific—not exploratory.
RFI closed after partial response. Provider sends lease but not invoice, and reviewer closes RFI anyway.
Partial receipt does not resolve an RFI.
Denial entered while RFI remains active. Reviewer denies request before second RFI due date has passed.
Denial cannot proceed with active RFI.
Shell built and routed, but Administrative RFI remains active. Intake sends RFI for missing housing support plan and still routes to Review same day.
Cannot route to Review while an Administrative RFI remains active.
Reviewer approves, but one required document is missing. Reviewer approves HTS, but lease is not uploaded or linked.
Approval requires complete and linked documentation.
Administrative RFI used for review-level judgment. Intake asks provider to prove medical necessity instead of just requesting missing documents.
Administrative RFI is only for Intake-level deficiencies.
Documents received but not linked. RFI closed. Documents are uploaded in attachments but not linked to the authorization before closing RFI.
Unlinked documents are treated as not reviewed.
Denial entered but rationale says: “Not supported” with no explanation of what requirement failed.
Denial must include clear, specific, supportable reason.
Intake builds shell but applies criteria in notes. Intake note says “Member appears eligible for HTS,” instead of just documenting receipt and documents.
Intake must not perform review-level judgment or decision-making.
Approval entered while an RFI was previously issued but not formally resolved. Reviewer receives docs via RFI but never closes the RFI before approving.
No determination may proceed while an applicable RFI remains active.
Review RFI issued when denial pathway is already clear. Member is already in stable housing and requests deposit support. Documentation shows no qualifying need. Reviewer sends RFI asking for “additional information” instead of proceeding to denial.
Do not use RFI when Decision Logic supports denial.
RFI response received with new information from the RFI, but you keep going with your original thinking instead of reevaluating the case.
When new info comes in, you have to stop and reassess the decision—not just keep going with the same plan.
Denial entered without confirming all documents are linked. Reviewer denies for missing lease, but lease is actually uploaded (not linked/reviewed).
All relied-upon documents must be uploaded and linked before denial.
Multiple services included in one shell. One authorization includes both Housing Transition and Sustainment in the same shell.
One authorization per HSS service type is required.
Reviewer approves, but rationale does not explain why requirements are met. Rationale says: “Approved,” with no connection to requirements or documents.
Rationale must explicitly support the decision for audit defensibility.
You request a signed lease and proof of move-in.
The provider sends a lease, but it’s missing signatures and move-in date.
You consider sending another RFI asking for a corrected lease.
Before sending a second RFI, you must decide if more information is still needed or if the correct pathway is already clear.
If the requirement still isn’t met and more documents won’t change the outcome, proceed with the appropriate pathway (denial or insufficient information).
RFI resolved, but pathway not updated (still shows “pending”). RFI is closed, but case status still shows pending instead of approval/denial.
Correct pathway must be selected after RFI resolution.
Multiple small inconsistencies across Notes, Summary, and Rationale. Summary says “denied for missing doc,” but notes say document was received.
All elements must align before determination or notice.
Shell built, but request is not administratively reviewable and no RFI was issued. PAR is missing key documents, but Intake builds shell anyway instead of issuing an RFI.
Missing information must be corrected via Administrative RFI or escalation before routing.
Approval entered, but record cannot be reconstructed from TruCare alone. Reviewer says “per provider email,” but nothing is documented or uploaded in TruCare.
Record must be complete, documented, and independently defensible.
RFI issued without identifying each missing item.
RFI just says “missing documents” without listing exactly what’s needed.
Each required item must be clearly defined and tied to determination need.
RFI resolved, but a new issue appears—review proceeds anyway. Missing doc is received, but now dates don’t match—and reviewer ignores it and moves forward.
Must stop and issue new RFI or escalate before determination.
Denial issued, but appeal rights or notice does not match rationale. Rationale says “missing income verification,” but notice references “non-covered service.”
Determination, rationale, and notice must align completely.