Anthem
Steps to remove a procedure code?
What is: If and ONLY if you have not saved the case yet (after adding a procedure code), you can click the "X" to delete the line, THEN you will save.
Benefit provision details, PCR rationale and resend as fax are all found here?
What is: The Letters Tab
Who attends Clinical Rounds and is responsible for evaluating members discharge?
What is: Many different health professionals can join; including Manager, Team Lead, PCR, Pharmacist, BH, etc.
Steps to change 1 SN visit to 15 SN visits?
What is: Clinical Review Tab - Procedure Code - Edit Pencil Icon - Update Quantity - Click the "X" - Save
Tool (not owned by Elevance) used by providers to submit case requests via portal, communicate to Elevance, and check on authorization requests. Eliminating the need for calling or faxing.
What is: Availity and/or ICR
Steps to generate letters?
What is: Clinical Review of case, Add the status and status reason, then hit save
What is a good way to ensure providers, members, and facilities will receive communication about the determination in a case?
What is: Ensure Letters generated
What impact does an accurate clinical review have on the effectiveness of treatment?
What is: It assists in determining the most suitable treatment course
Reasons to perform an Administrative Denial?
What is: If there are no benefits available for that particular request per the benefit plan, non-covered services, if benefits were exhausted
"Update Portal Validations"?
What is: The Intake Review Tab
All members have the right to an __________ if their inpatient or outpatient case was denied?
What is: Appeal
T/F: A case is created in ACMP and after it is created it will need to be transferred to an appropriate queue.
What is: False - the case is created in AUMI then it automatically transfers to ACMP
Radio button next to the "Include in Clinical Rounds/MD Huddle"?
What is: When the case needs to be brought to clinical rounds and reviewed by the staff for unsafe dc, medical complexity needs, etc.
Steps to transfer a case from within a case
What is: Case Details Tab - Request Details - Transfer Case - Enter Queue Name - Select appropriate queue - Transfer
Members address, COB, providers address, and transaction history are all found in what tab?
What is: The Case Details Tab
Once the PCR has entered a denial in the Physician Review, what are the next steps?
What is: Physician Review Tab for status and status reason > Clinical Review Tab - MATCH the PCRs status and status reason > Save > Letters > Validate Letter Rationale
3 places to find the PCRs denial rationale?
What is: The Letter Rationale tab and within the denial in the physician review, and in the physician denial rationale box in either service line or in IP view review details section
This tab pulls information in from many different tabs as a quick, explorative view.
What is: The Case Summary
The "TIME" it takes to process a request from start to finish is called the - what time?
What is: The Turn Around Time
What are some reasons clinicians would pend cases to PCR?
What is: If the case is questionable, if the case does not meet criteria or guidelines, LOB specific reasons, benefit exhaustion, non-covered services