Periodic File Review

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Across
  1. 3. On Category 2 & 3 Home Care claims, for the 24 month review, at PFR “prep” date, the Benefit Analyst must request a telephonic __________ Update from the appropriate care coordination supplier.
  2. 7. For MCD Category 2 & 3 home care claims, n addition to the onsite assessment, complete a Care Call with the ______________ and ______________'s care provider.
  3. 9. You should make a total __________ attempts to complete the Care Call.
  4. 11. The "_______" diary must be set one month in advance of the PFR completion diary, which is the PFR due date.
  5. 12. Conditions that are not expected to improve, or improve very little, with time and/or medical treatment (e.g., dementia, Parkinson’s, ALS). It would be reasonable to expect such a claim to be long-term.
  6. 17. Proof of payment must be requested on home care claims with ____________________ caregivers at least once during every 12 month period.
  7. 18. On Category 1 Home Care claims, a diary must be set to complete a PFR every ______ months during the first 24 months of the claim.
  8. 19. If the policy is with _________ months of exhausting on an ongoing claim, you may, at his or her discretion, waive the PFR.
  9. 20. The ________ call will provide you with the opportunity to confirm the Insured's long term care needs, clarify conflicting or incomplete information, address changes in the Insured's care needs or level or care, and resolve any questions or issues about the claims handling process
Down
  1. 1. Claims in approved status for one or more years should be sent to the _________ Leader under the subject: File Review – Periodic File Review – Requirement Waiver>1 year.
  2. 2. For Category 1, 2 &3 Injury and Sickness Nursing Home claims, for each review, you must request the most recent __________ form through the appropriate records vendor (i.e., ReleasePoint) one month before the PFR is due (at the PFR “prep”) to be completed.
  3. 4. Conditions that may improve with time and/or medical treatment, though the recovery period may be extensive (e.g., COPD, cancers, stroke). These are differentiated from chronic conditions because a reduction in care needs over time is more likely.
  4. 5. Conditions that are expected to quickly resolve with time and/or medical treatment (e.g., fractures, rotator cuff repair, knee replacement, sprains, and infections).
  5. 6. On Category 2 & 3 Home Care claims, a diary must be set to complete a PFR every ________ months during the first 12 months of the claim.
  6. 8. When a ____________ change occurs between scheduled PFRs, a full review for ongoing eligibility must be completed when you become aware of the change.
  7. 10. On Category 1 TQ Reimbursement ACF claims, for the 12 month review, you must request ______________ records from the past year through the appropriate records vendor, and an onsite assessment from the appropriate care coordination supplier.
  8. 13. For most claims, you will complete the Care Call only on _______ care claims.
  9. 14. On Category 2 & 3 Home Care claims, for the 4 month review, at the PFR "prep" date, you must request an _________ assessment from the appropriate care coordination supplier.
  10. 15. For Category 1, 2 & 3 Injury and Sickness Nursing Home claims, after an Insured has been on claim for 24 months, PFRs will not be ______________ on an ongoing basis.
  11. 16. On Category 3 Home Care claims only, for the 12 month review if the documentation indicates the Insured remains eligible with an Acute Condition as the primary diagnosis, the Benefit Analyst must consult with a _______________ Specialist to discuss recovery expectations.