Periodic File Reviews

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Across
  1. 5. 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.
  2. 7. This must be requested on home care claims with independent caregivers at least once during every 12 month period
  3. 10. On Category 2 & 3 Home Care Claims, a diary must be set to complete a PFR every ______ months during the second 12 months of the claim.
  4. 11. When this type of change occurs between scheduled PFRs, a full review for ongoing eligibility must be completed when you becomes aware of the change.
  5. 12. For Category 1 Nursing Home Confinements, you must request for each review the last 2 _________ forms and latest facility POC through the appropriate records vendors (i.e., Release Point)
  6. 13. On Category 1, 2, 3 Injury/Sickness claims after an Insured has been on claim for 24 months, PFRs will not be required on an __________ basis.
  7. 14. At the 24 month review on Category 1 Home Care claims, you must request a telephonic Status Update from the appropriate care coordination supplier.
  8. 17. If the policy is within this number of months of exhausting on an ongoing claim, you may at your discretion, waive the PFR.
  9. 19. For Assisted Living Facility confinements at the 12 month review you must records _________ records from the past year through the appropriate records vendor, and an onsite assessment form the appropriate care coordination supplier.
Down
  1. 1. 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.
  2. 2. This diary must be set one month in advance of the PFR completion diary, which is the PFR Due Date
  3. 3. 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.
  4. 4. This provides the BA with the opportunity to confirm the Insured's long term care needs and/or clarify conflicting or incomplete information
  5. 6. the documentation indicates the Insured remains eligible with an Acute Condition as the primary diagnosis, you must consult with a _____________ Specialist to discuss recovery expectations.
  6. 8. At the 6 month review on Category 1 Home Care claims , at the PFR "prep" date, you must request __________ assessment from the appropriate care coordination supplier.
  7. 9. Conditions that are expected to quickly resolve with time and/or medical treatment (e.g., fractures, rotator cuff repair, knee replacement, sprains, and infections).
  8. 15. A diary must be set to complete a PFR every six months during the first _________ months of the claim.
  9. 16. At the 12 month review on Category 3 (Acute) Claims Only,
  10. 18. For Home Care claims, after an Insured has been on claim for 24 months, a PFR must be completed once very ________ months as a >24 Month Review
  11. 20. The total number of attempts you should make to complete the Care Call