Acute DRG
What are the CMS guidance scenarios?
Ongoing IV treatments, Blood transfusions for ongoing bleeding/symptomatic anemia, 1:1 or restraints, Continued supplemental oxygen need above baseline, q4hr neuro checks or more frequent
What are clinical interventions
Task Description: TAT (TAT Date and time) HCA Readmission
What is the tasking description for HCA readmission when sending to the MD?
On day 5 of the approval period, request updated clinical information, discharge date, and disposition
When are you to Set up a Delayed Fax?
CS hub- Tools-Favorites-UM References
Where do you find the CMS IP only list and Fax back forms for acute?
Within the Clinician Review section, access the appropriate Clinical Review
What is the Note type for Level of Severity Re-Review?
UMNC can approve up to 10 days if clinical interventions are present
What is the maximum days UMNC can approve w/o sending to MD?
HCA Readmission Review, includes the index SA# and date of service “Potential for readmission linkage”
What is the HCA readmission Case note?
Requires a Med/Nec review beginning at day 7 or within TAT and every 5 days or once a week after.
How often do IPR/LTACH PDiem facilities require review?
Concurrent Review Clinician-Medicare
What JA has most of the process for acute medicare review for UMs?
Use approval reason: Approved HCA only; pay lower severity or Approved HCA only; pay higher severity.
What is the approval reason for HCA DRG cases?
MUST CUSTOMIZE: Per Diem/Percent Billed Denial - Medicare
What is the acute pdiem denial letter?
DRG contract
Request is for an acute inpatient admission
Discharge from index inpatient admission is within 30 days of the current admission
Index admission and current admission are to facilities with the same PIN/TIN
The Index inpatient admission received a separate approval.
A case can be linked regardless of severity level
What are the requirements for a DRG Readmission?
Complete the Post-Acute QuickBase (QB) Template in full:
Select Review Type: Initial Review.
Enter Rationale: SNF to SNF previously approved per SA #XXXX, Dates of Service XX/XX–XX/XX.
Cross‑reference and document the service authorization number in both cases.
Request MD review when the provider requests subacute level 3 or 4.
Document the review using Admission Criteria and Discharge Planning.
What are the steps for a SNF to SNF transfer when days remain current SNF auth and there is not a NOMNC?
Where you look for how to handle Hospice situations for our Medicare members
What is the Hospice Guidelines Medicare?
Discuss case with MD in case rounds or via case conference if complex discharge planning needs are identified OR the length of stay is over 60 days.
What is the process for DRG LOS >60days?
The provider must request the review by 4:30 PM the same day.
The Medical Director must complete the review by 12:00 PM the next day.
What is the timeframes for denials when provider is notified before 1pm?
UMNC may link Medicare cases without Medical Director review when the admission occurs on the same calendar day as the discharge.
What are Same day Readmissions?
At day 25, UMNC requests current clinical information and completes a medical necessity review with an MD referral*
When to send CMG IPR to MD for review?
Medicare Notice of Non-Coverage Provider Letter (NOMNC)
Where do you look for QIO appeal workflows?
Document using the discharge‑planning template and a case note
Enter a Correspondence Create note.
What are the case notes required for DCP for a member at a DRG facility when they remain in house?
The TL or AM will continue to review all EOD requests
Who reviews acute denial letters?
What are the Approval details on the SL for a DRG Readmission?
Precert Status Case note
What case note do you use when documenting a Dismissal?
Heart in MedCompass
Where can you locate whats new in UM?