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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