Potpourri
You have until July 24th to complete this task?
What is the mid-year check-in conversation with your leader and colleague?
True or False: A member only needs to be out of a post-acute facility for 60 days before their SNF benefit will restart—and if false, what is the correct requirement?
What is False, and the member must be out of both the post-acute and acute setting before their SNF benefit will restart (process #2)?
When the UMNC is entering the information received date and time in the header, which time zone should be used?
What is the time zone you are currently working in?
What does DENC stand for?
What is Detailed Explanation of Non-Coverage?
😊🛏️🤮💉🫀 Are these ok to use in a legal medical record?
What is NOOOOOOOOOOOOOOOOOO!!
Ongoing IV antibiotics, IV heparin, IV opioid medications, IV antihypertensives, as well as medications, 1:1 sitter, blood transfusion, supplemental oxygen, BiPAP, CPAP, and Q4 neuro checks—these are all examples of what type of intervention at per diem and % billed facilities?
What is clinical interventions?
When a UMNC does not receive clinical information from a delayed fax, when should a second request for clinical information be made?”
What is: on the last covered day (Process #10)?
True or False: For Post-Acute ESA-PPO plans, you should always select ‘pay at highest in-network benefit,’ whether the facility is Par or Non-Par.
What is True: always select pay at highest in-network benefit for both Par and Non-Par facilities?
True or False: It is appropriate to use italics, bold, or ALL CAPS in a DENC—and what are the correct formatting guidelines?
What is False: do not use italics, bold, or ALL CAPS; instead, avoid medical jargon and abbreviations and use full sentences in plain English?
The Medicare UR Page was updated to reflect this new standard pre-service turnaround time for post-acute requests, reduced from 4 days.
What is 3 calendar days from receipt of the request?
How often is the WNIUM updated, and where can you find it?
What is every other week, and it can be found on the CS Hub by searching ‘What’s New in UM’?
If a member admits after the scheduled admission date and the service line is updated with the acute admit date (without changing the approved-through date), what UM clinical note type is used to document the reason for the change?”
What is an Appended Clinician Review?
On a Par DRG facility, what level of care should be entered into the service line?
What is DRG, with the level of care adjusted if needed based on the facility’s contract (Process #21)?
If a member wins an appeal due to an administrative or technical overturn and a NOMNC is re-issued, what must be included in the new DENC letter?
What is: Bullet #3 must be completed based on the decision letter from the QIO?
When documenting a DRG readmission approval, what is the correct date format required for claims processing?
What is the mandatory 8-digit format: xx/xx/xxxx – xx/xx/xxxx?
When should a post-acute pending request be dismissed
What is: when a cancellation or withdrawal is requested and either the case is for a different level of care or there is no plan for the member to go to another facility (e.g., discharge to home), following the Medicare cancellation process?
When a case is discussed during rounds for a continued stay review and the MD approves, what is the appropriate case note and approval reason?
What is Case Conference (Clinician-MD) with the approval reason “Approved by clinician” (Process #20)?
True or False: When inpatient admission is approved and wesend a notification of approval we do not need to include thelevel of care in our documentation.
False: when completing our QB/CDST template we must include level of care in our documentation
Process #21
True of False: UMNC’s are responsible for creating DENC’s for home health services?
True
If a standard OD intent to deny is issued to a facility after 1:00 PM local time, by when must the discussion be completed?
What is by noon the following day, with the provider having until noon the next day to request the P2P discussion (calendar days)?
True or False: You can cancel a post-acute request when someone asks to cancel or withdraw it and the other case is for a different level of care.
What is False?
When a member has reached their SNF benefit level during a continued stay and a letter must be generated, what type of denial and denial reason should be used?
What is a customized denial with the reason ‘Benefits Exhausted – 100 Day SNF – New Request (Precert)’?
Medicare 100 Day-120 Day limit Exhausted
What claim payment instruction is used for re-admissions, along with the appropriate claims payment comment?
What is DRG Readmission, with the comment ‘Review for Payment and refer to original DRG admission (reference #)’ and the use of the Readmission Flag?
A UMNC issued a NOMNC, but the SNF reports the member plans to discharge home the next day. Do you still need to complete a DENC?
What is Yes?
What is the CMA’s responsibility for cases with coordination of benefits (COB)?
What is: CMAs oversee COB cases by conducting the investigation and verifying COB, then task the UMNC with handling the denial—including sending the letter and contacting the provider and member—while CMAs do not generate letters, and these remain classified as expedited ODs?