Preliminary
What service is being Denied ?
Outpatient procedure( Office visit & injection)
What was the source of this appeal A2135110111 ?
Fax
For appeal A24060696801 , how many SNF days used?
34 days
Name the two(2) QIO agencies?
Kepro & Livanta
Whats another term for "Case Number"?
Reference Number
Using case number A24129555287 , Who is the Requester?
Vasko Jocevski, is requesting on behalf of Afshin Skibba MD
How Does the Flow tell us to label our Providers?
Treating Provider
Provider( Facility)
Referring Provider
Whose information goes to Initial reviewer?
The MD who previously denied the Authorization
What are the age requirements for Inpatient and Outpatient Medical Records?
3 days for Inpatient and 1 month for Outpatient
Pulling up an appeal, where do you put the Case number?
Med Appeal# area
True or False: Leaving a message with a person other than the member/AOR/POA is considered a successful contact.
False
Leaving a message with a person other than the member/AOR/POA is not considered a successful contact.
CGX 2.0 and Navihealth
True or False, Nurse works on Weekend and federal Holidays?
False
What makes case A2135110111, and Expedite case?
Keyword Urgent
Where in MedHok can we verify Eligibility?
In 360member under eligibility which is listed under care
Where do you check to see if the member is on a Hospice VBID Plan and Engaged Hospice?
the Member Banner dropdown in CGX.
who is the IPA for this case and what is the preferred method of contact and the contact information
INTERMOUNTAIN HEALTHCARE // Secure Email// Aly.barreto@imail.org;UM-PriorAuth@imail.org
When do you update the Initial Review Completed Date field in the History section?
Update the Initial Review Completed Date field in the History section with the date you completed the initial review. ( once finish with initial review/ after changing the status)
Reference- Case set up step 19
Using the correct tool, Give the correct subtask business title and Due date.
On Monday 05/06/2024 Mellissa got an appeal that was due on 05/09/2024 2:30 Pm. The case is due in the next 2 days and will be sent over due to the Acknowledgement call being unsuccessful. Creating the subtask what should the business title and Due date be?
Nurse Review and 9 Am Same day as the Case due date
What radio button indicate medical records are not needed?
Additional info Required
Editing CGX denial page, what information is changed?
Contact method change to CCP2
Contact Name for appeals, type GACCP Reference Number Example: GA859885244812)
For appeals regarding a missed QIO appeal deadline, type GAQIOCCPReferenceNumber
Example: GAQIO859885244812
Highest decison level change to G&A
Source- Clinical Guidance Exchange (CGX) 2.0 Procedures, creating an Authorization step 4.
If members written and spoken language is Spanish, what step to be taken to send a letter in communications from blue banner?
Draft both (SP) spanish and English letter from communication. Save both English and Spanish letter on file without sending however Highlight the English service in the Spanish letter. Go to Translation SharePoint using Spanish only option, fill out applicable questions and upload both English and Spanish letter and await for response in your email.
Once service is translated you will update the Spanish version of the service in communication and send Spanish letter only.
When requesting Denial information a case note should be added, what is the case note type ?
Business partner Request
When no Expy verbiage with Nomnc, how do we handle this case?
email NOMNC to Market using HSO regional market excel and Downcode.
Where in MHK do we located cases reviewed by IRE(Maximus) ?
Under care at External appeal