Day 1 Provider Accountability
What type and section of a guideline should be documented and reviewed against for Day 1 (Short Stay) reviews?
Clinical Indications for Admission in either the RRG or GRG
How can you tell a difference between a continued stay case vs short stay case at the first clinical review?
Day 1 - no days approved at first clinical review. Continued stay - days already approved at clinician review, either administratively or after Day 1 review.
What are the names of our four Clinical Specialists?
Natosha
McKendrie
Alex
Tawnya
What should you do if an EMR flag is not working properly or if the webpage is incorrect?
1. Write down the CCA number
2. Inform Supervisor/Leads of EMR flag not working ASAP
What decision reason is used when approving a Day 1 review case?
Concurrent Short Stay Meets Criteria
When Intake receives an admit notification ONLY from a facility and sends the UM167 requesting clinical updates:
1. How long does the facility have to send us updated clinical documentation after providing timely notification?
2. How long How long does an in-network facility have to send us updated clinical documentation after providing untimely notification?
(2 points)
1. 2 FULL calendar days until 11:59pm PST on the date requested.
2. 1 FULL calendar day until 11:59pm PST on the date requested.
Clinical Specialists will send the UM103 if clinical not received by 11:59pm PST on the day requested on the UM167 fax.
What is the Case Closure Reason when a case is closed for Provider Accountability?
Administrative Closure for failure to follow filing procedure
What queue should cases be pended to if they're awaiting discharge confirmation after MD denial?
Clinical Admin Discharge queue
What does PCC stand for and what is its function?
PointClickCare (aka PreManage or CMT) is a software that speaks with facilities to Cambia including admit, discharge, and transfer dates, diagnosis codes, etc. Only some of our in-network facilities may be PCC affiliated.
What Decision Reason is used when pending days for post-service review?
Default
Intake received the admit notification on 3/28/25 along with clinical documentation indicating member admitted for MI and underwent 2 stents placed, hemorrhaged causing prolonged hospital stay, and discharged home on 3/27/25.
What steps should be taken to finish this review?
1. Updating case to reflect 3 days pending with "Default" decision reason.
2. Add note in case that case will be reviewed at post-service/claims.
3. Close case as Administrative Closure.
In what situations and case types can we not apply Provider Accountability to? (3 answers)
1. Out of Area and/or Out of Network
2. NICU/Maternity
3. PCC connected facilities with late admit notification
What case types are not to be sent to the Clinical Specialists?
Post-Acute (SNF/IPR/LTACH)
How can you know if a facility is affiliated or connected with PointClickCare/CMT/PreManage? (2 answers)
1. PCC flag in CCA
2. PCC Spreadsheet located in the Knowledge Hub
What Decision Reason is used when an MD denies an inpatient hospital continued stay review?
Concurrent Continued Stay Medical Necessity Criteria Not Met
Member admitted on 4/6/25.
Admit notification only was received on 4/8/25.
Facility is NOT a PCC connected facility.
Intake sent the UM167 and requested clinicals due 4/9/25 and were received on 4/9/25 indicating member meets medical necessity criteria for continued stay.
What actions should be taken to finish this review correctly? (4 steps)
1. Update extension line to reflect days 4/6/25 to 4/8/25 as pending with Decision Reason: Concurrent late admit notification failure to follow filing procedure.
2. Add extension line from 4/8/25 forward as approved for appropriate # of days.
3. Initialize Data for fax # to trigger auto fax
3. Pend case to next review date.
What steps should be taken for the following scenario?
Member admitted on 4/6/25.
Admit notification and clinical documents received on 4/9/25.
Facility is INN and is NOT PCC Connected facility.
1. Update extension line to reflect pended days from 4/6/25 to 4/9/25 (admit date to receipt of admit notification) with Decision Reason of Concurrent Short Stay Late Admit Notification Failure to Follow Filing Procedure.
2. Review from 4/9/25 forward.
3. Add another extension line to reflect decision made for review from 4/9/25 forward.
What are the Clinical Specialists no longer adding to every case they triage?
PCC Example Problem Part 1:
Member admits to hospital on 5/1/25.
Admit notification + clinicals are received on 5/5/25 and member does not meet criteria for continued stay.
Facility is PCC connected.
What action steps need to be taken next?
1. Adjust extension line to show pending days from 5/1/25 to 5/5/25.
2. Decision Reason: Default
3. Complete MD Review write-up and send to MD
4. Add second extension line beginning on 5/5/25 with 1 day pending for MD to review.
What Case Closure reason is used for the following scenario.
Days 1-3 administratively pended for provider accountability
Days 4-7 approved
Days 7-8 administratively pended for Provider Accountability
Admin Closure for failure to follow filing procedure
NICU baby admitted to IP hospital on 5/1/25.
Received IP admit notification only without clinicals on 5/5/25.
Intake sent UM167 and clinicals were received on 5/5/25 indicating baby born at 30 weeks gestation and meets criteria requiring NICU services for prematurity.
Facility is PCC connected.
What actions should be taken to finish this review correctly. (4 steps)
1. Document brief clinical write-up and approve days from 5/1 to baby's corrected gestational age of 38 weeks as NICU babies are exempt from Provider Accountability.
2. Complete CM Referral
3. Complete Potential High Cost Claimant Form.
4. Pend for review at next review date of 38 weeks corrected gestational age.
What CCA steps should be done when a facility fails to submit clinical information by 11:59 PM PST on the next review date after confirming successful fax of UM102 at previous review?
(MedA - 4 steps, Commercial - 3 steps)
1. Send UM103 requesting clinical in one day and await 2 calendar days before moving to step 2 (MedA Only)
2. Add extension line of 1 day and leave in pending status
3. Update Decision Reason pending: Concurrent continued stay failure to follow filing procedure
4. Close case with reason: Admin Closure Failure to Follow Filing Procedure
What is the clinician's role to complete in a case denial process when it's 4pm or later PST?
• Denial phone call(s) (member and/or provider depending on LOB).
• Send for assistance (denial letter)
• Pend to the Clinical Admin Discharge queue
PCC Example Problem Part 2
MD review came back agreeing with continued stay denial for the PCC connected late admit notification case. What action steps should be taken to finish the case review? (2 steps - include decision reason)
1. Update pending line to reflect denial decision with decision reason: concurrent medical necessity criteria not met.
2. Send to Clinical Admin Denial queue for the Clinical Specialists to complete the denial phone call(s) and send for assist for denial letter to be sent.
1. Continued Stay Provider Accountability pended days for lack of info
2. Short Stay late admit notification Provider Accountability pended days
3. Late admit and DC date received with pending for post-service review
1. Concurrent Continued Stay No Records Received Failure to Follow Filing Procedure
2. Concurrent Short Stay Late Admit Notification Failure to Follow Filing Procedure
3. Default