Core Values Dedication ~ Ingenuity ~ Community ~ Integrity Section 2: Telligen’s Idaho QIO Organization Chart Section 3: Idaho Medicaid Review Team Positions UM/QM Position Responsibilities Qualifications Senior Review Coordinator / Review Coordinator Performs prospective, concurrent or retrospective utilization review/medical management for all services including appropriateness of Quality of Care based on contract, state, or URAC requirements. Screens individual cases according to specific criteria to determine if care is appropriate. Refers cases that fail to meet criteria to peer review Enters medical information into system(s) Registered nurse or other licensed healthcare professional directly relevant to the type of review performed One to two years’ experience in a healthcare setting Valid Idaho license Functional PC knowledge Knowledge of medical coding, billing and/or utilization management preferred Medical Coding Analyst (future) Performs coding validation to ensure submitted diagnoses/procedures on claim are supported by clinical record documentation and appropriate billing Screens individual situations according to applicable coding guidelines to determine if coding is appropriate Refers cases that fail to meet criteria to peer reviewer Performs preliminary research on topics such as coverage determinations, coding guidelines or standards of care. Experience with ICD coding and concepts as well as CPT and HCPCS coding required Two years minimum experience in inpatient and/or outpatient coding. Certified Professional Coder or Certified Coding Specialist or Certified Coding Assistant or Registered Health Information Technician or Registered Health Information Administrator required
Section 20: Review Types Review Type Submission Method/ Review Components Description Time Frame to Completion & Notification Pre-Service Review Web portal Secure fax Telephone conduct pre-service reviews for selected diagnosis and procedures that require prior authorization Non-urgent; Fifteen calendar days Urgent; Three business days Psychiatric Hospital and Continued Stay Review under 21 Web portal Secure fax Telephone Conduct pre-service reviews of all admissions of Participants under the age of 21 with primary psychiatric diagnoses according to IDAPA 16.03.09 Sections 700-719 Pre-Admission Non-urgent; Fifteen calendar days Pre-Admission Urgent; Three business days Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Continued Stay Review for stays exceeding previously authorized hospital stays Web portal Secure fax Telephone Conduct medical necessity review of services that received pre-service authorization when the stay reaches the scheduled discharge date and discharge is not anticipated Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Continued Stay Reviews for all hospital admissions exceeding 3 days length of stay Web portal Secure fax Telephone Conduct review of medical necessity for diagnosis/procedures that do not require pre-service review when the length of stay exceeds three days Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Continued Stay Review for Cesarean Section hospital stays Web portal Secure fax Telephone Conduct review for medical necessity when the length of stay exceeds four days (only if the primary diagnosis code is identified as needing this review by the Department) Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Retrospective Pre-Payment Reviews Web portal Secure fax Telephone Conduct review for outpatient or inpatient hospitalizations where the primary diagnosis or procedure would have required pre-service review or when the hospitalization exceeded three days Within thirty calendar days from receipt of all necessary documentation Focused Case Reviews Web portal Secure fax Telephone Conduct review of complex cases, high cost procedures and other cases as requested by the Department Within fourteen calendar days of receipt of all necessary information
C09 Apparently did not obtain appropriate laboratory tests and/or imaging studies. This category is used for failure to order diagnostic (laboratory and/or imaging) studies that are deemed appropriate for the patient's condition. C10 Apparently did not develop and initiate appropriate discharge, and/or rehabilitation plans. This category is used for a lack of arrangements or plans for conditions continuing to require treatment and/or monitoring prior to or following discharge; failure to develop a plan that reflects an appropriate transition of care; failure to identify additional needed resources; failure to provide appropriate teaching; failure to transmit pertinent information. C11 Apparently did not demonstrate that the patient was ready for discharge. This category is used for failure to assure that the patient is stable enough for discharge to the setting into which the patient is being discharged. C12 Apparently did not provide appropriate personnel and/or resources. This category is used for lack of sufficient staff to handle patient load; lack of credentialed staff for provision of offered services; equipment unavailable to carry out treatment plan. C13 Apparently did not order appropriate specialty consultation. This category is used for those cases in which a specialty consultation that would have been necessary to adequately assess and treat the patient was not ordered. If there is a distinct clinical management concern over and above failure to order the consultation, cite that category as well, even if it is C03. C14 Apparently specialty consultation process was not completed in a timely manner. This category is used when a specialty consultation is not ordered in a timely manner or is not completed in a timely manner. If the only issue is the delay, do not additionally cite C03. If there is a distinct clinical management concern over and above the delay in ordering or completing the consultation, cite that category as well, even if it is C03.