Weekend Work
Who do you call off to for the weekend if you are unable to work?
Call Out Line: 855.515.0504 is for call offs on a scheduled weekend
What guideline do you use when reviewing a % bill or per diem facility?
CMS
What do you use for COB for a member that started their stay prior to coverage by Aetna?
custom2951 MUST CUSTOMIZE-Contractual–Acute IP started pre effective date–Medicare
The service(s) for you were started before your enrollment with our Medicare Advantage health plan. Our records show enrollment into our plan is effective on INSERT DATE XX/XX/XXXX. If you had coverage under a different Health Plan, contact that Health Plan. If assistance is needed for post discharge care, please contact us by calling Customer Service at the phone number on the back of your ID card.
Any expedited cases or Must Customize case must be sent to the AM or TL.
Who do you send member call notification to on Friday and through the weekend?
For calls for Saturday and Sunday you place on Wolfrey, Rebecca task list and back to primary UM for Monday.
Task Type: Monitor case
Task description: Member call, expires “add 72 hour TAT date/time”
Name 3 Clinical Interventions for %bill/per diem facilities?
Ongoing IV treatment
IV heparin
IVF
IV med
IV/IM sedation
Blood products
02 > than BL
Bipap/CPAP HFO2
Q4 or > neuro checks.
What do you use for member that have Aetna as secondary and GLOS is 0?
Review for contracted type send to MD
When do you use MCG for criteria?
For Par DRG facilities.
What is the MD bucket for OH/KY on the weekend?
What criteria do you use for NON PAR facilities?
less than 2 MN with d/c confirmed sent to MD
2 MN no d/c confirmed CMS 2 MN
What fit do you use for COB cases?
COB – Follow COB Protocol.
DRG readmission MD approves separate admission what do you do?
If meets MCG do DRG higher severity.
If not meeting MCG do low severity separate admission!
What can we do on Friday to help support weekend timely reviews?
Please do second request for clinical on Friday.
What is the difference in the dc verification update for % bill and per diem?
One says every 5 days and one line say every 3 days
Waiting verification on this.
NON PAR is every 5 days.
CM referral as been streamlined, name 2 reasons on why you should refer to CM?
Denied SNF admission
Long length of stay
MD recommendation
UMNC clinical judgement
Name 1 update to the Acute UM % billed and per diem job aid
· Removed the 48-hour provider clinical submission timeframe from the General Information section.
· Removed peer-to-peer scripting from this job aid and consolidated it into the Acute/Post-Acute Clinician Peer-to-Peer Organization Determinations – Medicare job aid.
· They added a direct link to route concurrent review staff to the peer-to-peer Medicare job aid.
· Updated the Timeliness section to align clinical request and decision timeframes with Medicare notification requirements.
· Clarified expectations for requesting clinical information.
(For acute initial requests, staff must decision the case within 48 hours to allow letters to enter the mail stream by 72 hours
Staff must make the second request for clinical information within the first 24 hours of receiving the initial request.
Staff must give the facility a clear deadline for submitting clinical information to ensure the case is decisioned within 48 hours.)
· Added CMS criteria to drive consistency in decision-making. (use CMS for % bill and Per diem)