UM Reviews
Where can you find Skilled Nursing Facility UM Reviews?
These are found in Teams in the care team specific channels designated for UM reviews (1_Col SNF_IPR Auths & 1_Nisq SNF_IPR Auths).
What does CQPIP stand for?
CQPIP = Coordinated Quality and Performance Improvement Plan
When would you use the dotphrase ".PACESDRUPDATE"?
This dotphrase is used when the SDR is taking longer to effectuate than expected to show that we followed up with the participant (or designated representative) and updated them on timeframe for effectuation.
How can a PACE staff member receive a grievance?
Any staff member can receive a grievance either verbally or in writing.
Where can you ask Quality or Compliance related questions?
Either our Compliance distribution list at PACE-Compliance-DL@multicare.org or our PACE Quality & Compliance Q&A Teams chat
Where can you find Inpatient Hospitalization and ED Visit UM Reviews?
These are found in the participant's chart in Epic as a Care Coordination phone visit.
For our CQPIP 2026 quality metric of Custodial Days PMPM, PACE is only tracking Custodial days in the SNF care setting. (True or False)
False, our 2026 CQPIP counts both the SNF Custodial and AFH Custodial care settings for our quality metric of Custodial Days PMPM.
What are the three types of request that define an SDR?
The request to initiate, modify, or continue a discontinued/reduced service.
What is a grievance defined as?
A grievance is a complaint expressing dissatisfaction with services or care furnished.
Where can any PACE staff member submit a performance improvement idea to the Quality, Compliance, Safety and Performance Improvement Committee?
The Performance Improvement Project Form, linked in email or teams.
How often are Skilled Nursing Facility (SNF) UM reviews completed?
These are completed every three days upon admission (weekdays only).
Which of the following does PACE track as a specific quality metric for our 2026 annual CQPIP? a.) Surgical Procedures PMPA, b.) Imaging Studies Ordered PMPA, c.) ED Visits PMPA, d.) Missed Appointments PMPA
C.) ED Visits PMPA
What are the parts required for an oral notification of an APPROVED SDR? (Two parts)
This notification must include 1.) any conditions of approval and 2.) the estimated timeframe for effectuation of the request.
Where are Grievances submitted?
Grievances are submitted into the HeRO system, they are never submitted or noted within the EMR (Epic) in order to maintain confidentiality of the Grievance.
What does the acronym CMS stand for?
CMS = Center for Medicare and Medicaid Services
Where can you find Miscellaneous UM reviews?
These can be found in leader ops or are provided to the person who requested the specific UM review.
Which of these is NOT a Quality Metric tracked for our 2026 CQPIP? a.) Reportable Pressure Injuries per 100 member months, b.) Falls without injury per 100 member months, c.) Voluntary Disenrollments, and d.) Advance Care Planning
We are not tracking a.) Reportable Pressure Injuries per 100 member months. Our 2026 CQPIP Quality Metrics are Falls without injury per 100 member months, Voluntary Disenrollments and Advance Care Planning (as well as Polypharmacy PMPM).
What is the timeframe for oral notification of both approved or denied SDRs?
Oral notifications should occur no later than three calendar days after the initial presentation of the request during IDT. (Same timeframe as the decision-making deadline if there is no extension).
How long does a participant (or their designated representative) have to initiate an internal appeal?
They have 20 calendar days from the day that they are notified of the denial or reduction of services (verbally or in writing, whichever occurs first).
Who is required to document disenrollment notes
using ".PACEDISENROLL" each time a participant disenrolls from the PACE program?
IDT members from that participant's care team, all eleven disciplines should be represented.
What are the five review types that our UM department covers?
The five review types are RAD reviews, Inpatient Hospitalizations, ED Visits, SNF stays, and Miscellaneous (reviews as requested).
For our 2026 CQPIP, our target for "Likelihood to Recommend Program" is 84%. Which of these is our 2025 baseline for this metric? a.) 74%, b.) 77%, c.) 80%, d.) 83%
Our 2025 baseline for "Likelihood to Recommend Program" is d.) 83%. Our 2026 target is 84% for a 1% increase.
What are the parts required for oral notification of a DENIED SDR? (Four parts)
This notification must include 1.) the reason for denial, 2.) that the participant has the right to appeal the decision, 3.) how to initiate an appeal, and 4.) that the participant will be receiving their appeal rights in the mail.
After an individual has exhausted the internal appeal process, they have the right to an external appeal through which agency?
They can appeal through Medicare or Medicaid.
What disciplines are required to complete in-person assessments for a participant's initial plan of care?
The eight disciplines are PCP, MSW, RN, PT, OT, AC, and HCC.