CASE MANAGER ORIENTATION

Utilization Review
Department of Care Coordination and Clinical Social Work

Name of Associate: ___________________________________Date: _____________

MEDICARE
Trainer: Brighid Williams, RN
_____________________________________________________________________________________
Please initial when completed: Trainer Trainee
Medicare Basics: Parts A, B, C, D w relevance to 2 MN Rule. Eligibility for
Medicare coverage.
Medicare’s 2 Midnight Rule: MD determination of Inpatient vs
Observation (Outpatient) Admission order & LOC. MD documentation vs
orders entered.
Exceptions to the 2 MN Rule: Medicare C List Elective Procedures,
Unexpected Clinical Condition Improvement, AMA, Death, etc.
IQ Application: relation to 2 MN Rule, referrals for Secondary MD review.
Review of ED workflow process and IQ LOC Criteria

MEDICAL/ CCS
Trainer: Lori Rothschild, RN
_____________________________________________________________________________________
Please initial when completed: Trainer Trainee
st
Medi-Cal FFS (Fee for Service). Medi-Cal Website. EHR review for 1 level.
Medi-Cal Assigned (Managed Care/HMO). Inpatient CM responsibility
CCS (California Childrens’ Services) Requirements for program. Website
access. SAR review
GHPP ( Genetically Handicap Persons Program)
Cencal Health (Santa Barbara Medi-Cal) Website access. Inpatient CM
responsibility

REVENUE CYCLE OVERVIEW

Trainer: Colisha Quinton, RN
_____________________________________________________________________________________
Please initial when completed: Trainer Trainee
Work Queue Review. Final Authorizations/ In-house Authorizations.
Types of Revenue Cycle CM (UR) communication requests to Inpatient
CM
Observation Status
Levels of Care/ Accommodation Codes review
IQ (Interqual) Review
Authorization/Certification Screen Review.
CM Module Review

1
 CASE MANAGER ORIENTATION
Utilization Review
Department of Care Coordination and Clinical Social Work

CMA PROCESS/ RETRO & APPEALS

Trainer: Britney Kirkwood, CMA or Alannah Smith, CMA
_____________________________________________________________________________________
Please initial when completed: Trainer Trainee
Retro and Appeal process review
CMA service responsibility
CMA WQ and Workflow
Next Review Date and BDT update review
LOC and INP order review ( INP orders and Transfer orders)
Denial faxes and communication between CMAs and CM
Utilizing online Web portals to obtain Final auths (e.g. Availity and UHC
web portal)
Payor communication

HANDOUTS PROVIDED:
_____________________________________________________________________________________
Please initial when completed: Trainer Trainee
Medicare/2Midnight Rule Orientation Handouts:
Medicare manual’s description of A, B, C D.
Noridian’s “Determining Patient Status Upon Admission”
CMS 2 MN Rule Process RR Workflow by Care Coordination Dept.
IQ’s “About Level of Care”
Provide Medical information with printed examples of FFS & Assigned
Website Links sent via Email: Medi-Cal, CCS, CenCal, and E.H.R.
National Provider Identification (NPI) numbers: Ronald Reagan and Santa Monica
CCS Website Access is provided with ID: LRothsch and Password: Winter 16—changes communicated by
Louisa N. when revised every 60-90-days.
Handbook for CCS Families
Summary of CCS Medically Eligible Conditions
Authorization and Claims for Genetically Handicapped Person Program (GHPP)
Observation Handout- How to determine if patient should be admitted observation
IQ training- 2016 training module

CMA Assigned Services Coverage