ACUTE REVIEW
If you have a DRG Par Facility and it is approved at low on the initial review, when does the case switch to high?
Where do you go to complete your TBTs
Learning Hub
What case note do you use if you have an HCA facility readmission review and the MD says to link it?
HCA Readmission Review
Who do you task P2P letters that will expire over the weekend to?
Kelly Smith RN
What is the case note to use when uploading clinical from the EMR for another nurse to review
Portal Review Completed
Discharge planning case note
Discharge planning template
Correspondence Create case note
Where do you go to find CRGs to join and expand your network within CVS
To join a Colleague Resource Group:
Go to Workday.
From the Menu, select the Quick Links.
Select Change Colleague Resource Group.
Select Add to join a CRG.
Under the Name section, use the search box to find CRG as the Affiliation type.
Select the name for the CRG you are interested in joining and relationship (Member).
Are UM Exempt Facilities subject to the readmission policy? If referring to the MD what type of determination is being requested?
1. Yes
2. Linkage determination NOT medical necessity review
When you are reviewing an IPR auth, and the facility is on the UM Exempt list, what are the steps for review?
• If no clinical is submitted, approve 7 days per clinician.
• A QB is still required for the initial clinician review.
• Document “unknown” for any fields where clinical information is not available.
• Rationale should read: “Approving per facility contract – UM exempt.”
For post-acute cases, in your eligibility note:
• Document “UM Exempt per Deviation list”
• You may also paste the relevant contract from SCM if available.
When should the Admission Criteria Case note be used?
1. UMNC completes AA process including E&E overide and the request is approved via automation
2. UMNC documents the QB template on an AA case that they have completed
3. UMNC manually approves initial days w/o clinical/medical necessity review including LOI low severity cases
When reviewing a pdiem par facility auth, what is the criteria you are using for the review?
CMS
What is the name of the resource/hub for Nurses to expand on career goals, network within the company
Enterprise Nurses Hub
What are the 2 exceptions on DRG Readmissions for not sending to the MD for linkage review?
1. Same day readmissions
2. No clinical received for index auth or subsequent auth.
If no appeal is filed w/ the QIO after a NOMNC is issued, what are the steps the nurse should follow on the case?
Enter discharge date equal to the day after the last covered day on NOMNC
Enter member discharged to field and discharge date field
Case is closed
What case types does the OD team review the letters for?
The OD Team does not review the following cases:
· Expedited Cases
· Admin Denials
· Acute CSR
· SNF CSR
The team does review:
· Post Acute Denials
· Dismissals
· IPR & LTACH CSR
· HIB (Admitted before the case was received)
· Air Ambulance
· Acute to Acute Transfers
When reviewing an acute authorization, if MC says the facility is NON PAR, but SCM shows the facility has a DRG Contract, which process do you follow?
What is the name of resource on the heartbeat page for mental health support that is no cost to you or household members?
Resources for Living
What instances would you not follow the readmission flag for an acute case review?
Facilities listed on the Provider Deviation list require the UMNC to follow their specific deviation language.
The DRG re-admission policy applies when staff conducts the initial admission review and may apply even if the decision is outside standard turn-around times (e.g., >72 hours from notification).
This does not apply to per diem, percentage billed, critical access hospitals or any Maryland facility.
Non-DRG Contracts
Transfers for a higher level of care. These are NOT readmissions and should not be linked under the readmission review policy (applies to acute care facilities only).
When a member files a Level 2 appeal on a NOMNC what is the tasking description and task type to use? How often are we to follow/check the case for a QIO decision?
1. Task Description: Awaiting 2nd level QIO appeal outcome
2. Task Type: Member Monitoring
3. 3 business days
In what scenarios would you follow the cancellation process for post acute authorizations?
Duplicate auth- same level of care
True clerical error was not intended to be requested
For acute denial letters, who's responsibility is to review the plain language in the long text for the denial letters?
Even though the MD’s are writing the verbiage, it is the responsibility of the UMNC to verify its accuracy and return it to the MD for any necessary revisions. As always send these letters to your AM/TL for final review of plain language and any needed assistance w/ correction of plain language.
Where do you complete your mid year and end of year self evaluations
Workday
A case meets for DRG Readmission Review when all of the following are TRUE:
1. DRG contract
2. Request is for an acute inpatient admission
3. Discharge from index inpatient admission is within 30 days of the current admission
4. Index admission and current admission are to facilities with the same PIN/TIN
5. The Index inpatient admission received a separate approval.
6. A case can be linked regardless of severity level
7. New request is NOT a transfer for higher level of care. ( These are NOT readmissions and should not be linked under the readmission review policy (applies to acute care facilities only). Exception: When members are transferred for higher level of care and then transferred back to the originating facility, the readmission review policy applies to the admission back to the originating facility.
If a member files a QIO appeal and there is no QIO decision w/in 48hrs of the initial appeals case note what steps should the nurse follow?
1. Staff contact the Fast‑Track Appeals clinician for an update.
2. Staff check the appeal status on the QIO website
3. Staff enter a case note:
SNF: Discharge Planning
Re-opening a case can only occur in what 3 scenarios are present?
1. Correction of clerical errors including human and mechanical errors on the part of the health plan such as mathematical or computational mistakes, inaccurate data entry, or the denial of claims as duplicates. There must be a note documenting what the clerical error was, and why the decision was made to reopen the case.
2. Instances in which there exists reliable evidence that the determination was procured by fraud or similar fault.
3. Procedural denials for lack of information are completed during the initial review, and clinical information is received within the reopen timeframe