Outreaches
MLK, Friday before Memorial Day, Juneteenth and the Friday after Thanksgiving
What are the holiday exceptions we can make an outreach on.
Should be suggested for members with insulin orders and reported manual dexterity issues
What is OT
Member/subtype exceptions to the member consistently on service for 6 months or more C3 rule.
What are Wound, Nephrostomy Tubes, B-12, and Foley members
Non-bundled agency
What is an agency Carelon will review SN for IV services
LSW
What is licensed social worker
Morning of next business day
What is when follow up outreaches should be done.
HHA is ordered for supervision, cleaning, and cooking
What is custodial care
Any documentation of this, even if it was years prior would qualify for BH subtype.
What is suicidal ideation
Section in portal where the C3 checkbox is marked
What is Member Information
CB
What is call back
Agency requests 8 SN visits but med nec is only seen for 3
What is DOV is needed
Reviewers will approve 1 week frequency for caregiver teaching for this need.
What is education on insulin administration
Type of drain that qualifies for C3
What is Pleurex
The note that all SN reviews will be documented on in the portal
What is C3 review note
DOV
What is discussion of visits
Before escalating a partial or full denial to the physician, if no previous outreach has been done by phone or fax, including a DOV, you must send one (1) fax outreach to the requestor
What is Adverse Determination Process
Request that will be approved for community resources.
What is MSW
Exclusion to LVAD criteria for C3
What is a member with LifeVest
First place to look to determine if the service provider for an IV member is bundled or unbundled on a reauth request
What is authorization notes
F
What is fax
If additional information is received at any time after the physician review, up to and until the SL has been adjudicated (flipped to approved/denied), the SL will be routed to Clinical Review
What is re-review process
Weekly visits will be approved for this skilled need for IV member's even when they have a caregiver to administer medications.
What are weekly dressing changes
Types of reauth requests that will never go to C3
What are therapy requests
Houses the template for C3 team lead email
What is C3 Teams site
LVM
left voice mail