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CCR Review Process
100

What is the turnaround time for a routine case?

15 calendar days

100
It is required to notify the provider of the decision for a routine case within how many days?

15

100

Tells you if the requested service needs precertification/ prior authorization

Aerial Benefit Plan (Ben Plan)

Member Details > Enrollment > Benefits Link

100

Name 3 types of Aerial Notes

1. Claim Note

2. Member Note

3. Case Note

100

Cases lacking clinical after 2 documented attempts to request for clinical can be _____________

Administratively Denied

200
How will you check if a member's policy is still active during the time of the request?

Check Aerial Policy Start/End Date

200

P2P reviews must be requested within ________ calendar days

21

200

Houses fax archives of clinicals

Alchemy

200

Provide 2 main clinical criteria guideline sources per the Clinical Guideline Hierarchy (cite which ones you will refer to in the correct order).

1. Internal

> UHC Medical/Drug Policy or CDGs

2. External

>  InterQual

> NCCN (for chemotherapy/imaging with cancer as primary dx)

> FDA (if no UHC drug policy available)

> LCD  (for DMEs)

200

Therapy treatment beyond 12 weeks for same condition without significant progress/complications and possible maintenance therapy should be _______________.

Presented to MD rounds

Source: Home Health and Therapy Visits SOP

300

The medical director will reach out to the provider requesting for P2P within _____ business day/s

1

300

A request that is deemed life threatening if not treated within 72 hours is considered ______.

Urgent

300

Houses group folders and allows you to locate documents containing covered/excluded services

ISTREAM

300

You receive a faxed clinical that says URGENT. What will you do with the task?

Change task priority to URGENT.

300

What will you do for requested codes that will not be used as part of the requested service?

1. Edit Request

2. Void Service

3. Enter Claim note

400

How will you handle Air Ambulance requests?

Send MD for secondary review 

400

What tasks must be done for Medical Director referrals?

1. Create task to MD (physician advisor/medical director)

2. Edit task assign to yourself (physician advisor/medical director), keep it assigned to yourself

400

Gives you an overview of covered/excluded benefits

HPBD (Health Plan Database)

400
How many attempts must be documented prior to rendering an administrative denial?

2

400

It is safe to render an administrative denial if it has been ___ days from the date of intake notification

13

500

Notification to providers for denied cases must be done via __________

Live Call/Voicemail.

Never fax a denial.

500

NCCN is appropriate to be used for case reviews of what type of oncology-related requests? (provide at least 1)

  • Primary diagnosis is oncology-related
  • Request is for Chemotherapy
  • For Radiation Therapy requests, UHC Medical Policy recommends use of NCCN for  further evidence-based criteria
500

It contains authoritative, scientifically derived information designed to support decision-making about the appropriate use of drugs and biologics in patients with cancer.

NCCN Compendium

500

Give 2 next steps after entering a decision in Aerial (Approve/Deny/Void)

Any 2 of the following:

- Ensure letters are sent c/o letter team

- enter case note

- close out task

- for OP only: check if case was closed

- for IP only: check if new task to IP RN was created

500

Request for IP stay for a patient who failed oral antibiotic therapy.

Dx: Cellulitis

CPT:  L02.612  Cutaneous abscess of left foot

How many days will you approve?

1 IP day per Intake Initial Screening Tool (Cellulitis)