Case Notes
The error code utilized to document any case note errors
Case Notes documented incorrectly (People)
The error code utilized to document any invalid or missing information in the RMD Form
Inaccurate or Missing information in RMD Form Correspondence (People)
The error code utilized to document missing attachments that are required for MD review
Attachment required for MD Review Missing (People)
The error code utilized to document incorrect effectuation date and/or time entered in MHK within the User Interface
Effectuation date documented incorrectly (People)
The location of the member's preferred language
The Blue Banner in MHK
Government Programs Addressing the Letter requires a case note to be added with these 2 elements
Address and where it was obtained
This is no longer in scope to audit within the RMD Form
Denied Provider Specialty
The error code utilized to document any missing attachments required as a result of the final determination
Required final determination attachments missing (People)
The error code utilized to document incorrect Review Comments or Claims Payment Notes in CGX
Authorization Information Section documented incorrectly (People)
Another word for an acronym used without explanation
Jargon
This case note is required when the acknowledgement call is unsuccessful
Case Note stating that you were unable to reach the member and the case needs to go for Clinical Review within 24 hours
If the state services rendered in is incorrect on the RMD form and associate has included the state in the subtask comments section, we should capture it utilizing this error code
Technology
This document should be attached for all appropriate plan years (if applicable)
The EOC
For an Inpatient Auth, if inpatient services where the member is currently in the facility being appealed, then associate should update this in CGX
Enter next review date in CGX, 5 days from MD decision
If a corrected letter is issued, this verbiage should be included within the newly created letter
This is a corrected letter
These 2 case notes are required when the IPA is responsible for effectuation and outreach is made for the update authorization information
What was requested and what was received
These 3 elements are required to be listed for any previously approved authorizations
The authorization number, ICD code(s), and CPT/HCPCS/Service codes
A screenshot of the authorization and of the authorization history in CGX should be attached to the case. These requirements are found in this procedure document
Medicare Advantage (MA) Pre-Service and Expedited Appeal Overturn and Partial Overturn Case Determination Procedure
For a DME Auth, if the MD does not provide an end date and the start date is retroactive, the end date should be updated to reflect this
45 days from MD decision
If the provider name populates like this (#&AppealProvider.TreatingProviderFirst#) in the About Your Appeal section of the determination letter, it should be documented utilizing this error code
Letter does not flow consistently (People)