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Auth Intake

QuestionAnswer
Inpatient Hospital 21
Ambulatory Surgical Center 24
Office 11
Home 12
AMB Ambulance
41 Land
42 Air/Water
Open This case is awaiting an action by a user.
Pending This case is waiting for background processes to be completed.
Resolved No further action can be taken on the case
Admnt Admissions Notification
CR Concurrent Review- Inpatient.
PA Prior Authorization- Outpatient
TR Triage Case- Fax when first received.
Triage Process performed by intake agents once a fax received to include reviewing the fax and determining how the fax should be processed.
Coordinate Will use all the information received from intake to ensure the faxes are sent successfully.
Clinical Reviewer Will ensure all details and InterQual Criteria and entered correctly
Medical review Coordinator(MRC) Will review to ensure all the information is completed correctly by all previous users. Once complete, the file will be sent for MD secondary Review. Will also complete peer to peer,
Medical Director(MD) Will review and make a determination. "Meets Criteria" cases got to the coordinator while " Criteria Not Met" will go to post-MRC. If information is missing, the case will go back to MRC.
OPEN CLINICAL REVIEW Initial review to determine medical necessity for a PA(Prior Authorization) case. PA(Prior Authorization) Clinical Review
Open INP Clinical Initial review to determine medical necessity for a CR(Concurrent Review) case. CR(Concurrent Review) Clinical Review
Open MD Review Secondary review to determine medical necessity on a PA(Prior Authorization) PA(Prior Authorization) MD(Medical Director) Reviewing
Open Approved Request has been partially approved and is waiting on user to complete task for resolution, expedited member call(Prior Authorization) or when a partially approved fax fails.
Open Partially Approved Request has been partially approved and is waiting on user to complete task for resolution, expedited member calls(Prior Authorization) or when a partially Approved fax fails.
Open Denied Request has been denied and is waiting on user to complete task for resolution, expedited member calls PA(Prior Authorization) or when partially approved fax fails.
Open Rejected Request has been rerouted and the reroute fax to the department.
Open Miss Info Additional information has been requested and the fax fails for a PA case.
Open INP Miss Info Additional information has been requested and is waiting on user to complete task so review can be continued on a CR(Concurrent Review) case
Pending Approved Request has been approved and is waiting on fax confirmation for resolution
Pending Partially Approved Request has been partially approved and is waiting on fax confirmation for resolution
Pending Denied Request has been denied and is waiting on fax confirmation for resolution
Resolved Rejected Request has been rejected and all requirements for resolution have been met. No further actions are needed on request.
Resolved Cancelled Request has been Cancelled and all requirements for resolution have been net. No further actions are needed on request.
Resolved Denied Request has been denied and all Requirements for resolutions have been met. No further actions are needed on request.
Resolved Partially Approved Request has been partially approved and all requirements for resolution have been met. No further actions are needed on request.
Resolved Approved Request has been approved and all requirements for resolution have been met. No further actions are needed on request.
OPEN- This case is awaiting on an action by a user
Pending- This case is waiting for background processes to be completed
Resolved- No further action can be taken on the case
ADMNT- Admissions Notification
CR- Concurrent Review- Inpatient
PA- Prior Authorization- Out Patient
Open Intake Data entry on a PA(Prior Authorization) request is occurring and being prepped for clinical review
Open Inp Intake Data entry on a CR(concurrent review) request is occurring and being prepped for clinical review.
Open Inp Review Secondary review to determine medical necessity on a CR(Concurrent Review)request and when receipt of consult has been complete by MRC(Medical Review Coordinator)
Open MD Request When a CR(Concurrent Review) case is routed to back to the nurse from the MD(Medical Director) when needing additional information.
Open MRC Pre MD A PA request is being reviewed by the MRC(Medical Review Coordinator) for completeness prior to a secondary review.
Open ScheduleP2P The case has a peer to peer scheduled and is in MD(Medical Director) review workbasket
Open Admin Review Administrative review is being completed on a PA(Prior Authorization) request
Open INP Admin Review Administrative review is being completed on a CR(Concurrent Review) case
Open Re Route PA(Prior Authorization) is being re routed to the appropriate internal department
Open referral Referral has been generated and is waiting on user follow up for completion
Open External Review When the MD or clinical Review nurse selects external review for a PA(Prior Authorization) case
Open INP External Review When the MD(Medical Director) or clinical review nurse selects External Review for a CR(Concurrent Review) Case
Open External Review When the clinical review nurse selects external review for a CR(Concurrent Review) case
Open Cancelled CR(Concurrent Review) request has been rerouted and the reroute fax to the department fails.
Open Consult Request reviewed by the MD(Medical Director) who sends the case to MRC(Medical Records Coordinator) for consult
Open Info Not Received When PA(Prior Authorization) Case was in Open Miss info and SLA timed out after 3 faxes were sent requesting info
Open INP info not received When Cr(Concurrent Review) case is in Open INP Miss info and SLA timed out after the clinical reviewer attempts to fax 3 times.
Open Info Received When A PA case was in Open Miss info and user made an update on the case OR a document was attached to the case
Open INP Info Received When a CR case is in INP Miss info and user made an update on the case OR a document was attached to the case
When a CR case is in INP Miss info and user made an update on the case OR a document was attached to the case Used when the PCP fax is waiting for confirmation after ADMNT
Pending miss info For a PA case, additional information has been requested and the system is pending a response to move the work item forward.
Pending Triage Faxes have been sent from triage stage and system is waiting on response.
PendingP2PReview When a PA request is waiting for the peer to peer to be scheduled
Pending External Review PA Request is with an external vendor and system is waiting on response to determine next steps.
Pending Rejected Request has been rerouted and the reroute fax to the department is pending.
Pending Cancelled CR request has been rerouted and the reroute fax to the department is pending.
Pending Consult When PA case is in external review stage for consult
Resolved Auth Required When the PCP fax is successful after ADMNT
Resolved Rejected(TRIAGE) A Triage case has been rejected and all requirements for resolution have been met. No further actions are needed on request.
Resolved Completed(Triage) Triage request is complete and no further actions are needed
Resolved Completed(Referrals) A referral(RF) PA case type is complete and no further actions are needed.
EOC Episode Of Care
What state does WMN belong to? Florida
TOC: Transition of Care
LOB Line of Business
PA Prior AUth
Member gets admitted into the ER and gets admitted, it is? Inpatient
Home Health 12
Out patient is considered CTD
What is Central Point You can find your job aids there.
Auth look up grid for par providers is used for? Looking up CPT codes, and it has the POS service on it.
Nurse Assignment List is used for___ To find the wellcare ID for a hosptial.
Wellcare Toolbox One source is to get the number for inpatients and outpatient fax numbers for requests for providers, to fax in forms(Outpatient Only) to give them the fax number off of form to fax in clinicals.
Find-A-Code: Usually just for fax agents. We use it to find DX codes that specify the description the provider put on the request.
Missouri Cheat Sheet The exact rules for Missouri. It's in your favorites and central point
MOD Missouri Medicaid
Transferring Calls Job Aid: Helps Transfer called to Prior Auth Nurse, Warm Transfer, Cause it's bad to do it cold. IT's also in your favorites bar on centralpoint. MLTSS are also in there.
We don't say help, we say ____. Assist
We only handle Medicare in ____. Florida
Coastal Care is _____ only. Florida
Meridian/Illinois is not a ____ transfer. Warm.
PA Nurse is not a _____ transfer. Cold.
New Jersey, Florida, and Missouri are ____ only. Phone Only.
Florida also has a LOB that WMN, you will see a pink alert that alert is gonna tell you that you're gonna give that member ___ days unless specified end date that provider needs. 90
Created by: MellonKanon
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