Case Updates
Can a provider be update on an already approved case?
Yes, as long as the TIN # is the same and provider INN.
When member is showing as default payer, what are the steps to follow?
Check SQL, verify in correct CRM, verify we review for code/plan & state and case should be placed on hold(Request for additional info).
If you receive a call from the health plan what pieces of information do you need to verify HIPAA?
Member name, member ID, and DOB
What is the TAT for 1st level expedited appeal for TX?
It is up to 72hrs.
What information goes in each chat?
Main chats:
Team Chat:
If update is made on a CWF case that is approved, who if anyone do you email?
Case updates for CEN & WC. FID is automatically.
When we receive an intake form and no clinicals are attached after making 1st attempt do we send to review?
No, you must make second attempt then send case to review
How will you ensure you do not miss HIPAA when getting interrupted by the caller during the call?
Any answer is a great answer as long as HIPAA has been verified!! Lol
What is the timeframe that PO can submit a retro for FID member for Cardiac?
14 business after procedure has been done.
Do you need to go in ACW to make OB call?
No, you just dial out.
When PO returns, the nurses call about downgrading to OP, what are we labeling call note as?
Sit of Steerage
When an intake is completed over the phone and 1st attempt and 2nd attempt have been done but dx code is missing do we send case to review?
No, case is to be placed on hold until dx code is receieved
If a provider office/facility can verify 3 pieces of information (name, DOB, and member ID), What can be used to substitute for the TIN/NPI for facility/practice?
Nothing, you need the TIN/NPI to verify HIPAA!
Do we handle sleep studies for MO?
No, not since 1/31/25
When do you use SQL?
Every call to make sure we are creating case in correct CRM.
What to do if member has a C or R ID, or as default?
We pull up in SQL as the IDs may/will convert or belongs in a different CRM.
If the facility/PO is showing OON do we send case to review?
Yes!
Who can we send auth letters to?
The office that created case.
What plans do we review for under Sunshine FL?
Ambetter, CMS(Title 19&21).
How do you place faxes back on the dash?
Go to your activities, select the fax. Then, top right three dots click assign. Assign to intake UM. Please let leadership know.
Are we allowed to update the facility on an approved case?
Yes, as long as facility is INN
Can you send case to review if case is sitting in draft?
No, please gather all case information and recreate while on the phone.
When can we speak to someone one other than the member?
If member is under 18 or if member gives verbal consent.
How do we handle a PSCR for HAP?
All the previous codes and the new codes will be on the new retro/PSCR case.
Please make sure to add a task to the case stating it’s a ‘PSCR Request’
For the Original case please update the start date to 30 days before the initial DOS. Please also task the original case with "Authorization expired, new case#.
Breaks / Lunches only need to be placed in team chat if what?
If over 5 minutes