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Medical Necessity Determination Process

Medical Necessity Determination Process. Assessments are reviewed by TMHP nurses within 3 business days of receipt. Assessments may remain in pending denial up to 21 calendar days. During this time additional pertinent medical information may be submitted for review.

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Medical Necessity Determination Process

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  1. Medical Necessity Determination Process • Assessments are reviewed by TMHP nurses within 3 business days of receipt. • Assessments may remain in pending denial up to 21 calendar days. During this time additional pertinent medical information may be submitted for review. • If an assessment is placed in a “denied” status, additional information must be received within 14 calendar days of the date of denial letter. Replaces slide 38

  2. Portal: FSI Replaces slide 63

  3. Corrections • If incorrect data on the MN and LOC Assessment is submitted or RUG of BC1 has been assigned, the provider can submit a correction. • Examples of incorrect data are: • Individual listed as a male but is actually a female. • Individual’s diagnosis notes diabetes but the individual actually has hypoglycemia. • Corrections are not allowed to all assessment fields (i.e., individual demographic information and assessment date). • Providers must access the assessment utilizing Form Status Inquiry (FSI) or Current Activity. • Corrections must be completed on the LTC Portal within 14 days of original submission. • TMHP will place the original assessment into a corrected status and give the new assessment a DLN creating a Parent/Child DLN relationship. Replaces slide 68

  4. Inactivations • MN and LOC Assessments can be inactivated from the system. • An example of an inactivation is when fields cannot be corrected. (i.e. Medicaid # and individual name) • Inactivations must be performed through the LTC Online Portal by a search through FSI or Current Activity. • There are no time limitations to perform an inactivation. • Assessment will be placed in a status of “Inactivated”. • Once the assessment is inactivated it cannot be “reactivated,” and a new assessment must be submitted. Replaces slide 71

  5. Status and Messages • Providers can retrieve the status of their MN and LOC Assessment by accessing FSI or Current Activity on the LTC Online Portal. • Medical Necessity (MN) Approved - Assessment has been reviewed and approved by TMHP. No further action by provider is required. • Pending Medicaid ID - The system is verifying the Medicaid ID. No further action by provider is required. Replaces slide 73

  6. Status and Messages (cont.) • ID Confirmed- Individual’s Medicaid ID has been confirmed for the dates of service submitted. Provider must submit/update all required assessments and forms. Replaces slide 74

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