general src #19, attachment 1: special services workflowahca.myflorida.com/itnr/region...
TRANSCRIPT
General SRC #19, Attachment 1: Special Services Workflow
General SRC #19, Attachment 1: Special Services Workflow Systems Used: TrurCare(TC)U
M N
urs
eP
rovi
der
/
Mem
ber
Med
ical
Dir
ecto
r R
evie
we/
refe
rral
C
are
Co
ord
inat
or
Car
ewo
rker
MCC
Load shell record into TC
Review case, consulting
appropriate guidelines and
decision hierarchy
All information present?
Work with ordering/requesting provider
within mandated TAT to complete
information
No
Review Case
Notify care coordinator of
decision, if appropriate
Clinical Review(UMP)
Needed?
Complete Clinical Template,
documenting rationale and
recommendation
No
Clinical Case Review starts
If a request is incomplete, the
provider is contacted via phone
or fax to obtain additional
information
Yes
Review auth loaded into TC
System (Corrpub) automatically generates approval letter to member
and provider.
Phone or fax provider notifying of
approval
No
ProviderPhone Call
ProviderPhone Call
Provider FaxProvider Fax MemberRequest throughCare Coordinator
MemberRequest throughCare Coordinator
Member Request for servcies throughMemebr Service
Member Request for servcies throughMemebr Service
Provider Online Request for Auth
Provider Online Request for Auth
Contact Provider to submit request
through standard methods for
provider submission
CW creates a task for the respective queue for the Licensed clinical reviewer to review for MNC.
Requires auth?Enter note
indicating that no auth is required
No
Requires auth?
Phone or fax provider notifying no need for auth and document
contact in notes
Yes
No
IP or precrt coordinator to void the shell and add a note after notifying provider no auth is
needed
Yes
System adds task to UM provider portal
queue sorted by level of urgency
Enter Approval Decision in TC as
“Notification Approval”
Letteres are saved in Corrpube
Refer to Medical Director
reviewe
Yes
Approve? No
Complete MD Review Template
EPSDT?
Conduct peer review with appropriate
specialist if needed
Dialogue with provider and/or peer if necessary
Yes
Document decision in TC
Decision MadeApprove
Pull case from TC Approval queue
UMPs or IP/OP coordinators may
enter approval Decision in TC based on MD
recomendations
Verify demographics and data is correct
(including fax number if
applicable)
Phone or fax provider notifying of
approval
Generate letter to Member and
Provider
letter filed in Corrpub
Deny / Alternative
Yes
Notify care coordinator of
decision, if appropriate
Consult with care coordinator as
needed, especially on potential adverse
decisions
Verify demographics and data is correct
(including fax number if
applicable)
Alternative offered?
Discuss alternatives with MD and CC
Contact provider to offer alternative and
ask provider to outreach to member
YesAlternative
accepted or no contact?
No
Document verbal order from MD for
alternativeYes
Add progress note indicating the MD name and order
information for the alternative
Update lines in TC and select correct
letter
No
Contact care coordinator to notify member of change
to order
Deny
That the denial correspondence team creates NABD that is created by Corrpub and faxed/mailed to provider and mailed to member.
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