Request Status Codes and Download Notes 3/7/08
As of 3/15/08 there are some additional status codes that will be used in CareConnection®. Below is the full list of codes, and examples of Provider Notes that may typically be included with the various status codes in the Download Notification.
CM Authorized
New Status: CM Authorized
Definition: Authorized as requested
Provider Note Example: Usually N/A
CM Authorized with Changes
New Status: CM Authorized w/ Changes
Definition: Request has been authorized at requested current level of service, however, the authorization end date has been changed and units pro-rated due to member eligibility issues or need for increased frequency of review.
Provider Note Example: Member is only eligible until 2/29/08. Please submit Continued Stay Review for remainder of authorization when member becomes Mainecare eligible. OR Authorized at current level. Please submit Continued Stay Review and provide additional documentation regarding discharge/ transition plan and inclusion of natural/ community supports to support transition to a lower utilization of units and/or clinically appropriate lower level of care.
Hold for Provider Information
New Status: Hold for Provider Information
Definition: Request has not been authorized and is being held for Provider to contact Care Manager to provide additional clinical information or clinical rationale needed to make a determination.
Provider Note Example: Additional clinical information needed to make a determination. Please contact (Care Manager’s name) at APS Healthcare, 1-866-521-0027 Ext. XXXX by X date (deadline will always be 5 days after the review has been submitted).
Denial Due to Lack of Provider Information
New Status: Denial due to lack of Info from Provider.
Definition: Request has been denied due to provider not responding to Care Manager request for additional information within requested 5 days.
Provider Note Example: same as the definition above
CM Renegotiated
New Status: CM Renegotiated
Definition: Provider has called Care Manager to provide additional clinical information and, based on discussion and clinical presentation, the initial request has been renegotiated and agreed upon by both parties. The provider must then contact the member and the renegotiation must also then be agreed upon by the member. The Care Manager will authorize the renegotiated amount when the provider contacts the Care Manager and reports the member is also in agreement.
Provider Note Example: Care Manager notified by (Provider name) on X date that provider and member have agreed to renegotiation.
Hold for Physician Review
New Status: Hold for Physician Review
Definition: If renegotiation of a request does not occur, and there still does not appear to be enough clinical information to support the level of requested units of service and /or requested length of stay, the request will be held for review by the APS Medical Director/ Physician Advisor.
Provider Note Example: Held for physician review. Determination to be made w/in X# of days.
Partial Authorization
New Status: Partial Authorization
Definition: Request may be partially authorized if the Physician determines with the Care Manager that the clinical presentation does not support the level of requested units of service and/ or level of care for requested length of stay.
Provider Note Example: Partial Authorization of XXXX based on physician review. Supporting documentation specific to the case and determination will also be provided here. Letters will also be sent via US Mail, at this determination (Please see Appeals/ Grievance Process).
Denial
New Status: Denial
Definition: If the Physician determines with the Care Manager that the clinical presentation does not meet Level of Care the request may be denied.
Provider Note Example: Member does not meet LOC based on physician review. Supporting documentation specific to the case and determination will also be provided here. Letters will also be sent via US Mail at this determination (Please see Appeals/ Grievance Process).
Administrative Close
New Status: Administrative Close
Definition: Request is closed due to data entry error, duplication of request, or request to resubmit review.
Provider Note Example: Provider incorrectly submitted request as Prior Authorization. Provider resubmitting request as Continued Stay.
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