CRITERIAS & POLICIES
This subset is intended to be used when a patient's condition, symptom, or finding is not included in a condition-specific subset.
General Medical
HOW OFTEN DO YOU EMAIL YOUR PRODUCTIVITY TRACKERS
DAILY
DMHC CASES HAVE A _ TAT
2-DAY TAT
JOB AIDS, CHEAT SHEETS, TEMPLATES, & MEETING MINUTES CAN BE FOUND HERE
OneNote / PDR and MRU Sharepoint Site
What are the 3 types of Trauma criteria
Physiological, Anatomic, and Mechanism of injury
What do you do when you find that the member was incarcerated at time of service
Deny authorization as Member is not Eligible.
THIS IS WHERE YOU LOOK FOR AN < 21 APPROVED, PENDING, OR DENIED SAR COVERING THE SERVICE, PROVIDER, AND DATES ON THE CLAIM
PEDI WEBSITE
Post service group has a courtesy of _ hrs to respond to clarifications
24 hrs
Self-service, My Tickets, Access Approvals, and Ask Max can be found in
Request Central
Commercial LOB: Service rendered by non-par and no criteria is found, what is used to support review?
EOC
This association promotes the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People
WPATH
Any day during the first 7 days of the hospitalization that meets for Episode Day 1 at any level of care (LOC) within the appropriate InterQual Subset, means the entire inpatient stay can be approved.
DRG
_______ is our Senior Manager
Jami Kendall
This spread sheet lets you know if the Provider is Per Diem or DRG
FFS Hosp Inpatient Method MCL Spreadsheet
How often is LTAC and SNF reviewed?
Every 7 days
Resources we use to support investigational/experimental services
Hayes and/or NCBI
WHAT LEVEL OF CARE (LOC) DO WE NOT REVIEW FOR?
WHAT IS OBSERVATION LOC
You have __ hr(s) to call in before the start of your shift
1 hour
System applications can be found here
Centene Connect
What criteria do you use for trauma?
American Committee of Surgeons (ACS) trauma criteria as well as local county guidelines
81420
There are services and items that have limits, once limits have exceeded, medical review is required. What type of review is this?
Max Benefit Reviews
Cases over $__ MCAL or $__ COMMERCIAL, require physician review
$75k MCAL & $125k COMMERCIAL
YOU CAN LOCATE EOCS IN THESE (2) PORTALS
Omni & OCOE
If the Provider is requesting Rev Code 0169, what is the request?
Administrative Days