Case Workup
In LTCM this letter is requested at the end of week 3 if there has been no engagement.
What is the Non‑Response Letter?
This documentation area must be updated by the primary CM, and should be updated as needed and within 5 days of case closure.
What is the Case Summary?
When you first receive a case, the engagement status is considered this, and you type it in Case Summary comments under Engaged/Barriers/Contact Mode.
What is “New”?
In Large Case Management, a non‑responsive member can be closed after this many outreach attempts over this time period.
What are 6 outreach attempts over 30 days?
If a member discharges home without engaging in Case Management services, this role is added as secondary and becomes responsible for medication review and provider follow‑up.
Who is the RN Case Manager?
When the member has no phone number on file (or it’s disconnected), you must check these sources before contacting Eligibility or the Account Manager. Name 3 sources.
What are medical records, MyCare, Zendesk, and calling recent providers
When documenting a provider call, your entry must include the phone number plus this “who” detail.
What is the name(s) of the person(s) spoken to and the information obtained?
Engagement becomes “Engaged” only after an RN‑only activity occurs and then this happens on a different day.
What is a second successful contact on a different day with a two‑way interaction?
During closure, this engagement status must not be changed if it already reflects certain values. Name one.
What are “Yes,” “Enrolled‑Active,” or “Family/Caregiver”
The MedCom COC Request Form instructions state members must apply within this time window if requesting COC due to a terminated provider or as a new enrollee requesting continued care with an out-of-network provider.
What is within 30 days (of the provider termination date or the enrollment effective date)
Before calling a provider, the SOP says provider details may be gathered from five sources. Name 4 of them.
What are the precertification report, claims, benefit calls, clinical records in the case file
An entry becomes locked and you spot an error after that. How long are entries locked in UMWEB and what is the entry to include in the note?
2hrs, "Correction"
PHQ‑2 must be completed for all members except these two groups.
What are minors age 0–10 and members in documented mental health therapy/counseling?
A closed case must be routed to High Dollar monitoring if these clinical or financial indicators are present. Name three.
What are inpatient stay claims, cancer diagnosis, transplant activity, or ongoing high‑dollar claims
For an RD consult, the initial appointment is this long and must avoid this timing mistake.
What is a 60‑minute initial meeting, and you shouldn’t schedule same‑day (give 24 hours’ notice)?
When a member stops responding to scheduled calls, the SOP requires this action before continuing to schedule new Calendly appointments.
What is following the re‑engagement call process and then proceeding with case closure if outreach fails?
Name two “case summary sins” explicitly called out by compliance even if the rest of your documentation is solid.
Leaving “TBD” in the case summary
Leaving the diagnosis as “Illness, unspecified”
A member actively participates for the first month, completes goals, and engages in education. Over the next six weeks, they miss scheduled calls, respond intermittently to emails, and stop following up.
At what point does this become disengagement, and how should engagement status be reassessed over time?
Once Engage, always engage
Name 5 things that must be true before a case can be fully closed without audit risk.
What are: all outreach documented correctly, anticipated claims reviewed/Stop Loss addressed, all tasks completed, discharge letter sent if required, close‑case entry completed, and care plan finalized appropriately?
When a member requests not to be recorded during an outbound call, this specific Genesys control must be used and the request must also be documented.
What is selecting the Unlock (star) icon to turn off call recording and documenting the request in the Patient Contact entry?
A member meets CDM clinical criteria, but the sponsor has not elected Chronic Disease Management. How do you know this MM has not elected CDM and What is the correct action
The CM must not refer the member to CDM because sponsor election of both Wellness and CDM is required. Referring without sponsor election creates a benefit misalignment and compliance issue, even if the member meets clinical criteria.
Where must Micromedex cost‑analysis results be documented once received? (Name 2)
CM Cost analysis
Care Plan → Cost Containment / Care Coordination section, and
Case Summary → Cost/Savings section.
A member under a sponsor that uses Coral Care Navigation is scheduled for an MRI at an outpatient hospital. The member answers your call, confirms the appointment details, but says, “I already have it scheduled and don’t want to change anything.” You explain Coral as a preferred care navigation option that could significantly reduce their out‑of‑pocket cost if coordinated through Coral. The member listens but declines to engage further and proceeds with the original facility.
From an engagement and documentation standpoint, how should this interaction be handled
A CM is closing a case and identifies that the member qualifies for CDM but also has high‑dollar claims requiring stop‑loss monitoring. According to the SOP, what is the correct workflow?
The correct workflow is to refer the member to CDM AND open to Disease Management with Triage High Dollar, ensuring stop‑loss monitoring continues. The most common mistake is closing the CM case and referring to CDM only, which can cause loss of high‑dollar oversight and stop‑loss exposure.
Before a CM can document HCUP avoided admission savings, what three documentation conditions must already exist in the case?