Reference Guide Utilization Management Intake...CESD/6.2016 WellMed Medical Management Page 2 of 67...

Reference Guide Utilization Management Intake

CESD/6.2016 WellMed Medical Management Page 1 of 67 For Internal Use Only

UTILIZATION MANAGEMENT INTAKE

The purpose of this job aid to assist the UM Intake staff to Navigate TruCare and enter data from providers request into the member electronic medical record.

Prerequisites

UM INTAKE SOPs, click CTRL + click is a hyperlink to take you directly to SharePoint SOPs.

Contents

CONTENTS

Utilization Management Intake .................................................................................. 1

Prerequisites ........................................................................................................ 1

General Information ............................................................................................. 3

Search for a Member ............................................................................................ 3

Verify Member Eligibility ........................................................................................ 6

Eligibility Issues ................................................................................................... 7

Steps in Adding a New Member .............................................................................. 7

Add a New Member............................................................................................... 8

BHP NODE ........................................................................................................... 9

Temporary ID ...................................................................................................... 9

Search for a Newly Added Member ......................................................................... 9

Document the New Member ................................................................................. 11

PCP Search ........................................................................................................ 12

Review the Authorization History .......................................................................... 13

Create the Authorization Record ........................................................................... 14

Duplicates and No Authorization Required ............................................................. 15

Adding Attachment to the Contact Note ................................................................. 16

Pre-Screening the Authorization Request ............................................................... 18

Complete Start and End Date ............................................................................... 19

Complete the Primary Diagnosis ........................................................................... 20

Delete Diagnosis ................................................................................................ 21

Select the Service Type ....................................................................................... 21

Complete the Servicing Provider ........................................................................... 22

Provider Search .................................................................................................. 23

Facility Search ................................................................................................... 24

http://sadcsp02/medmgmtops/carecoord/Job%20Aids/Forms/AllItems.aspx?RootFolder=%2Fmedmgmtops%2Fcarecoord%2FJob%20Aids%2FUM%20JOB%20SOPs%2FWellMed%20Job%20Aids%2FPrior%20Authorization%20%2D%20Intake%20Job%20Aids



Searching for an OON Provider ............................................................................. 25

Complete the Prescreen Place of Service ............................................................... 27

Complete the Prescreen Primary Procedure Code .................................................... 28

Perform a Prescreen Check .................................................................................. 29

Prescreening continued ....................................................................................... 30

How to Add a Note ............................................................................................. 31

Authorization Screen ........................................................................................... 33

Diagnosis Section ............................................................................................... 34

Requesting Provider Section ................................................................................ 34

Out of Network Request ...................................................................................... 35

Complete the Line Item Detail Section .................................................................. 36

Place of Service and the Office Visits ..................................................................... 37

Next Task Section ............................................................................................... 38

Standard, Expedited and Retrospective Request ..................................................... 40

Click Add Document. ........................................................................................... 43

Attach the Fax ................................................................................................... 43

Requesting Medical Records ................................................................................. 44

Add Note ........................................................................................................... 51

Pre-Screen and Levels of Inpatient Stay ................................................................ 52

Levels of Inpatient Stay ...................................................................................... 53

Readmissions ..................................................................................................... 57

Servicing Facility ................................................................................................ 59

Service Type – Place of Service ............................................................................ 60

IKA-Advanced Training for MCR Role ..................................................................... 63

UB Claims .......................................................................................................... 64

Reprocess the Claim ........................................................................................... 65

Verify Claim Adjudication (Payment) ..................................................................... 66

Forwarding the Claim .......................................................................................... 66



General Information

There are two types of authorizations in TruCare:

Inpatient, which includes inpatient & observation, LTAC, acute rehab and SNF

Outpatient, which includes everything else

Authorizations entered in ePRG that flow to TruCare will:

Apply the referral rules based on the market rules.

Pend directly to the Clinical Review (Prior Authorization Nurse) queue if the service requires clinical review.

Records that are attached through ePRG will be in the attachment section.

Requests received via fax will be managed by the intake teams.

Each CPT/HCPCs requested:

Must be entered on a separate line item. Requires a prescreening to determine if authorization and/or clinical review is

required. If the member is in a Medical Home Market specialist referrals will auto approve.

Approvals and denials cannot be entered on the same authorization.

System users will only have access to members (markets) and system functions, which are associated with their role in the organization.

Search for a Member

Staff only have access to members for which they perform activities.

A wildcard search (look for everybody) is done with the underscore (_).

From the user dashboard, click the Member hyperlink in the Global Header.



Click Member Search.

Complete any combination of the data fields.

Generally, all that is required is the last name, first name or plan ID.

Click Search.

The search result table populates.

Choose the member from the member table by clicking Open.



The members file opens in a tab. Consider it the first page of a members chart.



Verify Member Eligibility

The eligibility listed in the member information Navigation Pane.

Check IKA for eligibility if not found in TruCare.

Create Temporary IDs to put in the authorizations.



Eligibility Issues

If Then

Member is found

and eligible

Review eligibility & plan information (BHP) in the

navigation pane. Proceed with data entry if authorization is needed.

If the authorization is a duplicate

Create a customer service note documenting provider notification that no authorization is required and save

document to note.

Member is found

but not eligible

Confirm eligibility per current process

Check IKA for eligibility NOT Eligible – Follow process for non-eligible members

email IKA Eligibility Inquiries with the Patient Name, DOB, and ID Number.

Member not found but you find they

are eligible

Eligible – Enter patient as Temp, put in authorization and notify supervisor and IKA eligibility email for member

to be updated in TruCare Temporary member files will be merged, by a supervisor/manager, when the data feed file is received

from the health plan.

Member not found Confirm eligibility per current process

All member's will be entered into TC for temp IDs if eligible - notify your supervisor or manager and

manual entry the member in TC Not an member-follow process for non- eligible members.

Steps in Adding a New Member

Search for the member.

Member cannot be found.

Eligibility is confirmed. Member is added through member search.

A New Member note is added in the Note Summary. A task is sent to the manager for tracking for member reconciliation.



Add a New Member

Enter Last name, First Name and DOB.



BHP NODE

When the POP up boxes come up select No then Yes.

Temporary ID

A temporary ID is assigned. Click OK.

Search for a Newly Added Member

Enter Last and First Name then click Search.

Then Click Open.





Document the New Member

In the Member header go to Documentation > Notes Summary.

Choose New Member Add in the Select dropdown list.

Click Create Note.

Enter information available.

Enter PCP by clicking Provider and choose PCP.



PCP Search

For the PCP search the Network must be set to All.

Enter Action Completed i.e. [email protected], your name and job title.

Click Submit, Begin Action for which member was added.

mailto:[email protected]



Review the Authorization History

Expand the authorization pod.

The expanded authorization pod.

Click View Summary to open the Authorization Summary Tables.

Do a high-level review for duplicate authorizations. If the service is not an obvious duplicate proceed to entering the authorization. Click arrow next to authorization number and the line items will open.

Or hover over authorization for a view.

Click Authorization to expand see

screen below.



Create the Authorization Record

Review the service request.

If Then

The services do not require authorization.

Notify the provider no authorization is required. Do not enter an authorization. (See the immediately following section on documenting this

call in TruCare.)

The request has both services that do

not require and authorization and services that do require an

authorization.

Notify the provider that no authorization is

required for the items that don’t require an authorization. Enter an authorization for only the

services that do require an auth.

The authorization is to more than one provider.

Each provider requires a separate authorization.

The authorization is Admin Approve and another service is for clinical review.

2 separate authorizations are necessary.

Click the authorization type to be entered.



Enter the Date/Time of the Request (fax time stamp or date/time of a call).

Duplicates and No Authorization Required

From the document dropdown menu choose Note Summary.

In the Select dropdown choose Customer Service Note.

Click Create Note.

In the Note Category choose Outbound Call Note from the dropdown list.

Choose the Contact Reason from the dropdown list.



Write a contact note starting with the service.

Adding Attachment to the Contact Note

Add attachment if needed. Complete Outcome and Contact Name. Click Submit.

If sending a notification, copy and paste history of Right fax to the Note and Submit.

Request for service from Dr. Jones. Called to Stacy to

notify no auth is needed. L Fletcher, LVN



A completed note can be found in Note Summary.



Pre-Screening the Authorization Request

Prescreening check for:

Eligibility

Duplicates If an authorization is required If the service can be auto approved

This is done after all the documentation is entered, the manual checks listed in the training aid

avoid unnecessary data entry.

An asterisk (*) indicates a mandatory field.



Complete Start and End Date

Enter the Start and End Date.

Examples of services and procedures and time frames for start and end dates.

If Then

Ambulance 7 days

Dialysis 6 months

DME purchase 90 days

DME rental 90 days except CPM – 21 days Life vests = 30 days

Wound Vac = 1 month Oxygen = 13 months

Specialty bed for SNF = Length of SNF stay

Home Health 60 Days

Oxygen 13 months

Procedure with known date.

Date of the procedure

Procedure with unknown date.

11/11/2032



Complete the Primary Diagnosis

Select Diagnosis Type. The application defaults to Medical.

Enter either Diagnosis Description or ICD code.

Click Diagnosis Search.



The Diagnosis table will open. Click the diagnosis on the table, the diagnosis will be added to the authorization.

Delete Diagnosis

To delete a diagnosis click the red X to the right of the diagnosis code.

Select the Service Type

Select the service.

Type from the Service Type dropdown menu. The first letter can be entered to search.



Complete the Servicing Provider

Provider Search

General Information

An underscore ‘_’ in the last name field can be utilized for a generic search.

Individual = physician and physician extenders.

Facility = all other providers.

The default is ‘Individual’.

Network

Participating limits the search to providers who are in the global network.

To limit a search to providers those who are in network for the Member, the search context selection must be member.

Not Participating limits the provider search to out of network providers. All will include both in and out of network providers. The default setting is All.

Hint: TruCare may not have the updated information for a Provider and IKA is used for research.

Supervisor will have exception lists available.

Search Context

Limits provider search to In or Out of Network based on the Member Network.



Provider Search

Medicare and Medicaid Participating

If the member is an MA member the Medicare participating must be PAR.

If the member is an MA-SNP member the Medicare & Medicaid participating status must be PAR.

Advanced Criteria

Advanced criteria can be applied to your search to limit the results based on additional criteria. Criteria include city, state and specialty. The use of advanced criteria is helpful if the

search is for an out of network provider.

More than one Advanced Criteria can be applied

If the provider is not listed choose Unknown and complete the Provider Add/Change process by submitting the PIC form.

Hint: Intake staff is responsible for changing from TEMP to correct Provider after Contracting

loads.



Affiliation

The affiliation is the In or Out of Network status for the provider as related to the Member.

The first physician listed is Out of Network for the member, the third physician listed is In Network for the member. The MC indicates the physician accepts Medicare.

Facility Search

2. Enter Date of Service.

1. Change from Individual Provider to Facility.



Searching for an OON Provider

Change to All if searching for an Out of Network (OON) provider.

Confirm/change the Medicare and Medicaid participating option.

MA=Medicare PAR

MA-SNP= Medicare and Medicaid PAR

Apply Advanced Criteria as needed.



Click Search.

Click Search.



Choose Provider from Results Table by clicking Select.

Complete the Prescreen Place of Service

Choose the Place of Service from the dropdown box.

Hints on finding place of service:

Typing ‘P’ will take you to the ‘P’ part of the list. Typing ‘P’ again will take you to the next ‘P’

entry. Office visit is the 4th option starting with Professional (physician) visit, so type ‘P’ 4 times.

If Then

Ambulance Ambulance Air or Ambulance Land

DME Home

Home Health Home

Labs, Radiology Office

Office Visits Office

Outpatient Procedures Outpatient Hospital

Ambulatory Surgical Facility

Outpatient Rehab Other, Comprehensive

Dialysis End-Stage Renal Disease Treatment Facility



Complete the Prescreen Primary Procedure Code

Enter the primary procedure description or code. The code is the preferred search term if provided on the request.

The code submitted on the request must be used. If no code is submitted on the request the intake staff must call to request a code.

Click Procedure Search.

The procedure search results table opens.

Clicking the procedure moves it to the prescreening.

To clear/delete the procedure code click the red X to the left of the Procedure Search button.



These codes used for home health services.

Social workers diverted to the Care Management Social Workers by tasks.

Nurse G0154 PT G0151

OT G0152 OT G0152

SLP G0153 HHA G0156

Perform a Prescreen Check

Prescreening is required for each service line (HCPC or CPT) requested. Prescreening must be done one service at a time by entering and erasing the

Primary Procedure Code in the prescreen section.

Click Prescreen.

Review the prescreen results.



If Then

Auth is required Proceed

Auth is not required Notify provider no auth required; cancel entry and add note in General Notes

Authorization is not a duplicate Proceed

Authorization is a duplicate Cancel-notify Provider and add Note in General

note

Can be auto-determined = No Proceed

Can be auto-determined = Yes Proceed

Prescreening continued

Pre-screening additional services.

1. Click the X to the left of Proceed/Search to delete the first procedure. 2. Enter the next procedure to screen.

3. Click Pre-screen. 4. Repeat for each requested service.

When all prescreening is done click Continue with Auth.



How to Add a Note

Return to the authorization, click Add Note.

1. Click Add Note.

2. From the Note Type dropdown list choose the appropriate Intake Note.

If Then

Hospital or UM Intake Team, TCM

Intake Note

SNF SNF Notes

Medical Claims

Review

MCR Note

3. Complete the Note fields.

4. In the Free Text Note, add pertinent information. If no additional Notes needed, add your signature.

5. Click Add Note.

Complete the fields in the intake note. In the Note field, enter pertinent information. If there is nothing to document, type your First Initial, Last Name and Title.



Scroll down the template page to click Add Note, if this is inpatient admissions please add

room number for onsite INPT CM.



Authorization Screen

Choose the:

Request Source

Method Level of Urgency Urgency Requested By

From the dropdown menu.

If Then

The request is for future services. Standard

Requested as expedited, urgent or stat.

Expedited

The request is an extension for home health or outpatient therapy for

member currently on service.

Concurrent

The request is from a provider for a

member that is discharged from services.

Retro

The request was received via a claim. Claim

Complete as necessary Continuity of Care and Court Ordered. Skip Member Eligibility and

SCA.



Diagnosis Section

The Diagnosis will automatically pre-populate from the Prescreening. Additional diagnoses can be added by clicking the + button. These diagnoses do not flow into the Member Pod.

Requesting Provider Section

Click Search. Change Individual Provider to Facility if needed (Example, from Home Health Agency). The provider who submitted the request is the provider to be entered if it is not the

PCP.

Click Select to choose the provider from the list. If the provider is not listed choose Unknown. Follow standard procedures to add the new provider.

Call provider and fill out the Provider Information Change Form. Enter the name of the Provider, address, phone number, and contact person in Notes and send PIC

form to Contract Help Desk.

In Network Box

The box will automatically check if an In-Network Provider is chosen.

Hint: Enter Provider Last Name and Title, First Name. It should auto-populate unless they

have several locations.



In this section, an Out of Network Provider does generate a Reason box.

Out of Network Request

From the Out of Network Reason dropdown list choose the Out of Network reason.

NA - utilized only if the provider is in the member’s network but not correctly identified in TruCare.

The Authorization Specific Contact is not mandatory, but should be completed if an office contact is listed or you will need to contact later.



Complete the Line Item Detail Section

The first Add will be the service listed in the prescreening.

Enter the Place of Service code if required. For office visits the E&M (Evaluation and Manage) will auto-populate if just an office visit.

Confirm the Service Type Start and End Date Place of Service

Procedure Code will be changed for the next service.

Change Requested Units and the Unit Type to match request:

Days, Units, and Visits

Click red X to change the Primary

Procedure Code.

Click Copy for additional service

needed. One service per line item.



Place of Service and the Office Visits

Enter the Place of Service code if required and for office visits, the E &M will auto-populate.

Required PL Codes

AM Air Ambulance

AM Routine Transportation unless covered by plan benefits

EM Office visits for new and established members

OT Outpatient OT (minus eval)

P3 Cardiac Rehab

P5 Pulmonary Rehab

PT Outpatient PT/OT (minus eval)

ST Outpatient ST (minus eval)

(If in Network box is not checked then the Out of Network Reason Select box opens).

Choose the reason for the Out of Network Referral from the dropdown list.

NA should be utilized only if the provider is in the member’s network but not correctly identified in the system.

Click Submit.



Next Task Section

The Next Task assigned in two ways: automatically by TruCare workflows, or manually.

Next Tasks assigned to a queue or an individual. There are four primary queue that are listed in a dropdown list for Next Task.

Secondary queues and individuals are assigned by:

1. Entering Next Task as UM Clinical Review Task. 2. Clicking the … button.

3. Clicking on an individual or 4. Using the dropdown box to select a secondary queue.

The queues are:

Primary Queues

UM Clinical Review Task Prior Auth Nurses

UM Advisor Review Task Medical Director Review

UM Determination Task Clinical Review done but no

Approve/Deny documented



UM Notification Task Correspondence Team need to send to either Approve or deny

Secondary Queues

Assessment Pends to CM/DM team for an assessment

Expedited Clinical Review Expedited PAN requests

Screening Pends to CM/DM team for screening

UM Advisor Review Medical Director Determination

UM Authorization Corrections Medical Claims Review

UM Evaluate Advisor Review Medical Director Response

UM Notification Sends to Correspondence Team

Due Date - leave the default.

Priority – Priority assigned based on request status. The default status is High.

Standard Request = Low Priority

Retro Request = Low Priority Expedited Request = High Priority (24-48 HR turn around)

Prospective Requests that Prescreened as Can be Auto Determined = Yes

Do not set a Next Task.

Click Submit.

Line Item Approves.



Standard, Expedited and Retrospective Request

Standard and Retrospective Requests

Choose the Next Task of UM Clinical Review.

Change Assigned To UM Clinical Review. Change Priority to Low.

Expedited Requests

Choose the Next Task of UM Clinical Review. Change Assigned To UM Expedited Clinical Review.



Change Priority to High.

Tasks that can be approved from a non-licensed staff directed by the UM Management team to allow administrative determination.

Choose the Next Task of UM Determination.

Change Assigned To yourself. Set priority to match authorization.

Completing the determination. Go to the member header and click Tasks.

Choose All Tasks. Click on Determination Task.

Click on Determination task.



Administrative Approvals - Send to the UM Approval Notification queue. *Only Administrative

approvals requiring correspondence from the correspondence team should have this task set.

Click Next Task to task to Correspondence.

Using the dropdown box for Next Task choose UM Notification Task.

Using the dropdown box, select the priority that matches the authorization.

Click Submit.

Save or Submit.

IF Then

The data entry is NOT complete and the request should

not go to the next task This used only in emergency circumstances.

Save

The data entry is complete and ready for the next task. This is the expected outcome for authorization entry.

Submit

If the status on the authorization summary table is Draft, the authorization has not been

submitted. Click Edit.

Scroll to the bottom of the authorization. Click Submit.

Using dropdown box change status to Approve then change explanation box to Approved Administrative.



From the Member header click Documentation, then Documentation summary.

Click Add Document.

Attach the Fax

Choose Document Source and Document Type from the dropdown list.

Type in the Document Control Number (DCN) using these standards. Choose Receipt Date of documents. Place authorization number in the Comments section.

(Failure to enter authorization number will be reported to your Supervisor.)

Click Browse to retrieve the document, then click Open to attach the document.



The document is added to the document table.

Requesting Medical Records

1. Confirm the File Name in the File Name field. If it is not the correct

file, click Browse and find the correct document.

2. Click Add.

3. Click Submit.



Close the Document Summary view by clicking red X.

The intake team is responsible for the initial request for medical records.

Recipients are to the Requesting Provider & PCP.

User Notes

Letters may require a User Note. User Notes are numbered, and are listed in the

body of the letter under <user note #> and on the User Note tab. The User Note tab will list the information that should be manually entered.

The User Note directions must be deleted. Failure to delete the directions will result in the directions printing in the letter.

The User Note number in the letter matches to a User Note data entry field.

On the Authorization Summary table highlight then click the authorization line.

Click Notification or go to Notification on submit when in the Authorization edit. Create Letter

Notification.

Check the line item for which a letter will be sent.



Choose who will receive the letter. Click the Recipients tab.

Choose the print/fax method for the requesting provider (Local Print to send through RightFax).

Enter the User Notes in Medical Records Request Nurse Reviewer. Scroll down and complete all User Notes with direction.

Need to enter the date and time by which the records need to be received. Delete the directions as the User Note is entered.

Failure to delete the note will result in the directions printing in the letter.

User Notes add the specific information for the letter. User Notes are manually entered.

They are entered in the text fields in the User Note tab. The Request for Additional Information letter has 4 User Notes.

User Note 1 The recipient fax

User Note 2 The date of services rendered

User Note 3 Other information needed Intake does not need

User Note 4 Records needed by and the date

Ex: Records needed by 3/16/2016 (3 days)

Select the letter to be sent from the dropdown box.



No images should be attached.

Preview the letter is optional.

Submit the letter. The application will open all requested letters in a single PDF file.



Click on page to print or fax.

Click File, Choose Print.

Choose printer name or RightFax printer. Change print range to Current Page.

Click OK.



Choose the printer name and click OK. It will send the document to the printer.

Choose RightFax Printer. Click OK will open the RightFax Utility box. Complete based on the RightFax process. (Add Provider Name, Fax Number).

Account - Authorization Number Matter - member last name Click Send.

Repeat for each page to be faxed by clicking on the page in the PDF and sending to the RightFax Printer.



Close the PDF document when all print and/or faxing is completed.

Copy History To/From RightFax document that was sent authorization. Highlight the document

sent.

Click History in tool bar.

Copy the transmission record to include: Time and Date, Unique ID number and resulting status code – Success.



Add Note

In TruCare click Edit for the authorization the document was sent and click Add Note.

In the Note field:

Copy and paste History from RightFax.

Click Submit.

Inpatient includes inpatient & observation, LTAC, acute rehab and SNF. The entry for Inpatient

is Entering an Inpatient Stay is very similar to the Service and Procedure with a few variations.

Complete the Pre Authorization Activities.

Click the Create Inpatient Request.



Complete the received Date/Time.

This is the date that the notification of inpatient services received or identified by WellMed. For Inpatient Case Managers, it is the time the stay identified on a portal, by a call received

requesting/notifying of the services or an order for a transfer to SNF/LTAC/ARU was identified on the chart.

Pre-Screen and Levels of Inpatient Stay

Update the Owner as necessary.

Click the ellipse button to the right of the owner name. Choose the owner from the user table.

If Then

Future Surgery Do not change, updated at time of admission.

Claim Do not change, updated at time of review.

Concurrent Enter the Inpatient Case Manager or Telephonic

Utilization Review Nurse assigned to the facility.

Retro Enter the Inpatient Case Manager or Telephonic

Utilization Review Nurse currently assigned to the facility.

Pre-Admission for LTAC, ARU or SNF

Do not change; they are updated at the time of admission.



Click Pre-Screen and complete the pre-screen fields. The pre-screen fields must be completed in order, to allow the Place of Service dropdown menu to populate.

Dates of Service From To

Member still in Date of admission Next day

Member DCd Date of admission Date of discharge

Future Surgery Date of Admission Next Day

Future Surgery with unknown date

11/11/2032 11/12/2032

Levels of Inpatient Stay

Different level of Inpatient Stays:

If Then

Observation Observation

Acute Hospital Medical for all levels of care (ICU, Tele, etc.)

LTAC LTAC

ARU Rehabilitation

SNF Skilled Nursing Facility

The steps for entering an inpatient authorization are the same as service and procedure.

Complete the Service Facility. Complete the Diagnosis and Procedure. The second prescreen is for eligibility.



Can the authorization be auto-approved? All inpatient stays will be No, as clinical review is required on all facility notifications.

For all inpatient stays, authorizations are required and cannot be auto-determined Per Prior authorization list.

Add the authorization note (all roles that enter an intake).

Click Continue with Auth when Red * are completed.

Note Clicking X to Close the pre-screen will lose all of the date before prescreen is completed.

Click Add Note when complete.

Once the

authorization is submitted, the note is

completed. To check go to View Note then Update.



Click Add Note hyperlink. Choose the note type from the Note Type dropdown field. Complete the fields.

Requesting medical records: the UM Intake team must request records (see the Step list Creating UM Correspondence) if none are received with the request. See SAR

Complete the Note field.

If Then

Intake: in-net Room Number, Your Name

Intake: OON/OOA Demographics for facility, UR phone number, Your name.

MCR Your name

TCM Admission identified on hospital portal 10/15/2014 @

6:30 AM. Signature

Orders for DNF identified on 10/15/2014 @ 2:15 PM Signature

Orders for LTAC at discharge identified 10/15/2014 @ 11:15 AM Signature

Call Received from Dr. Welby 10/15/2014 @ 10:30 AM requesting transfer to SNF at discharge. Signature

Complete the authorization section of the authorization:

Complete the request source, method and level of urgency.

https://s3.amazonaws.com/wellmed000/LMS/MedicalManagement/TruCare_5_3_SARS/Requesting_Medical_Records_Notifications.pdf



Determine is this a concurrent, retro or a standard timeframe inpatient stay?

If Then

Member discharged, but notification within 1

business day of admission

Concurrent

Member discharged and notified >1 business

day after admission

Retro

Member still in the hospital Concurrent

Pre-Admission for SNF, LTAC or ARU Standard

Future Surgery Standard



Determine Admission Type and Admission source

If Then

Through the ER Type: Emergency

Source: Emergency Room

Direct Admit from

Provider Office

Type: Urgent

Source: Physician

Emergent facility to

facility transfer

Type: Emergency

Source: Transfer from HC Facility

Elective facility to facility

transfer

Type: Elective

Source: Transfer from (appropriate choice from dropdown list)

Future Surgery Type: Elective

Source: As appropriate from dropdown

list

Readmissions

Complete Readmission.

Readmission defined as an admission to a second facility within 30 days of a discharge, and includes all diagnosis and all levels of care. The exception applies to any transfer to a lower

level of care within 24 hours of discharge. Example: Discharge from inpatient hospital stay and admission to SNF.



Using the readmit dropdown button choose YES or NO.

Add Additional Diagnosis - all appropriate diagnoses need to be attached to an authorization.

Enter either the description in left field or the ICD-10 code in the right field.

Click Diagnosis Search - The Diagnosis Table opens.

Click the correct diagnosis - the diagnosis is pulled into the authorization.



Servicing Facility

In the requesting provider section, enter the attending/admitting MD.

1. Click Search. 2. Select provider type, the default is provider

3. Update the date of service (network status is based on date of service). 4. To search for an out of network or unknown provider change to All.

5. Complete the provider of facility name. Facility names must match the computer listing exactly.

6. Click Search

7. Choose provider from the results table by Clicking Select.

1. Click Search.

2. Search for an select the facility. 3. If the facility is unknown enter unknown which comes up as unknown, intake or CTA

enters a note with provider information: Provider name, address, phone and fax

number and a contact person (designated person complete provider information change form and upload form to TruCare).

4. Link to PIC Form. 5. If applicable, choose the out of network reason from the dropdown list.

Facilities are considered out of network if they are outside of the member service area.

https://eprg.wellmed.net/Account/Login?ReturnUrl=%2fupload%2fpdf%2fWM_PIC_Form.pdf



Complete the line item 1: new line item. 1. Some information will be pre-populated with data from prescreen. 2. No changes are needed to line item type.

3. Confirm that the request date and time have pulled accurately form the previous entry.

4. Confirm the line item from the line item to data. 5. Complete the service type and place of service.

Service Type – Place of Service

Complete the Service type and Place of service.

Service Type Place of Service

OBS Hospital Outpatient Outpatient Hospital

Inpt Hospital Inpatient Inpatient Hospital

SNF Skilled Nursing Care Skilled Nursing Facility

ARU Rehabilitation Inpatient Inpatient Hospital

LTAC Long Term Care Inpatient Hospital



Complete the Next Task Section.

Click Next Task. Choose UM Clinical Review.

Complete the assigned to:

IF Then

TCM creating case

for self

Click the ellipse button and assign to self.

Failure to assign to self-drops the authorization into the Prior Authorization queue.

a) If this happens, go to the Member Header > Tasks > all tasks.

b) Claim the review.

Intake creating for TCM

Click the ellipse button and assign to appropriate TCM.

Intake creating a future surgery

Leave with the default ‘UM Clinical Review’.

MCR sending for clinical review

Click the ellipse button.

Change the user menu to Group Queues.

Choose UM MCR <market>.



Complete the due date based on request of urgency and day received by WellMed (any WellMed employee or department).

If Then

Member is inpatient

Same day

Future Surgery Expedited: 3 days

Standard: 14 days

Retro/MCR 30+ days depending on contract

Complete the priority of inpatient stay.

If Then

Member is

currently inpatient

Medium (Concurrent)

Future Surgery Low (Standard)

High (Expedited if requested)

Claim review Low (Retro)

Click Submit.

IKA is the claim system that Claims uses to pay or deny claims. This Reference will assist in viewing the IKA and using the Queues within this system.

Need the claim ID for the authorization comments/notes.

In order to prevent duplication, make sure there are no authorizations in for this provider

and for service for this period. If no auth is in, begin entering claim information into a new

authorization.

Required fields to be filled out by claims all have asterisks *



IKA-Advanced Training for MCR Role

Claims information:

Received date (date it comes into the organization) Status of claim ID-identifier for claims and should go in comments for authorization

Patient information:

Click on patient ID arrow for Eligibility and PCP for time of the Services. Open TC authorization entry and begin putting in a new authorization.

Copy and paste patient information from the claim to a new authorization.



Provider information:

Click on arrow for billing provider to bring up contracting information. Then you can see if

the provider is nonpar (non-contracted) or par (contracted).

PCP number and name

ICD codes Choose Claims detail tabs for notes, EOB note, for history or for any other

information added.

UB Claims

(Uniformed Bill) This is for facility or high dollar item:

Information on HCFA claims (Health Care Financing Administration) Claim for

anything other than a facility



Service date and revenue codes (CPT codes)

Hover over CPT/HSPC and it will tell you what the code is.

*** At this time we are not using Service groups and all CPT codes must be put in the

authorization to adjudicate (pay). ***

Remember to look for all dates and if there are numerous pages, look at all the dates and revenue codes to ensure proper authorization entry.

Every claim has to show the dates specific of service and the service they has received.

The service dates must be within the appropriate time frame of this claim.

Reprocess the Claim



Click Reprocess After entering authorization and it has been approved. If it is pended, you do not need to Reprocess until a determination is made.

Verify Claim Adjudication (Payment)

Go back up to top of the claims page to ensure adjudicated.

Forward to claims with a note and the auth number if it does not adjudicate.

Forwarding the Claim



Select claim you want to forward by clicking in the select box to see a check in the My Claims section of your dashboard.

Click work flow. Choose either #9 HCFA Claims (for miscellaneous services) or

#8 UB claims (for facility), depending on how the claim was processed.

Click Follow-up to put in your work flow to check daily on status. Put in comments - i.e. approved auth # 11111111111 and then forward.

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