InterQual Review Manager Guide to Conducting Reviews. McK. Change Healthcare LLC Product Support

Transcription

1 InterQual Review Manager 17.0 Guide to Conducting Reviews McK Change Healthcare LLC Product Support

2 General Terms: Change Healthcare LLC and/or one of its subsidiaries ( Change Healthcare ) is the owner/licensor of the InterQual and InterQual Review Manager products, including the software and clinical content ( Clinical Content ; collectively referred to as the Work ). Change Healthcare has prepared the Work for exclusive use by its licensees of software applications embodying the Clinical Content. The Work contains confidential and trade secret information of Change Healthcare and is provided to licensees who have an existing license agreement in force only under the time-limited license as provided under that license agreement. Licensee and any recipient thereunder shall use the Work in accordance with the terms and conditions of the license agreement. If You Have Been Provided Access for Evaluation Purposes: Change Healthcare is the owner/licensor of the Work. Change Healthcare has prepared the Work for exclusive use by its licensees of software applications embodying the Clinical Content. The Work contains confidential and trade secret information of Change Healthcare and, if you have been provided access to the Work for evaluation purposes only, is provided to you only under a nontransferable, nonexclusive license whose term is limited to the time frame set forth in the notification sent to you containing your access password. You and any recipient hereunder shall use the Clinical Content in accordance with the terms and conditions of this license and the notification. You are granted this license solely for the purpose of your internal evaluation of the Work as part of your decision whether to license the Work, and for no other purpose. You expressly agree to keep the Work confidential and not to release or disclose the Work to any other third person without Change Healthcare's express written permission. Further reproduction, including but not limited to the printing of any portion of the Work or results obtained as part of the permitted evaluation, adaptation, incorporation into other media, and release of the Work by you is strictly prohibited except upon prior written permission of an officer of Change Healthcare. Notwithstanding the foregoing, any copies or reproductions of the Work made by you during the limited evaluation term shall be destroyed and shall not be used for any purpose upon the expiration of the term. Proprietary Notice: The Work is protected under United States and international copyright and other intellectual property laws. If this Work is delivered pursuant to a federal government contract that requires the conveyance of rights in data to the government, it is understood that the Work, including commercial software, clinical content, third-party software, documentation and/or other technical data, was developed exclusively at Change Healthcare s private expense, and that Change Healthcare will convey only limited or restricted rights in the Work to the government consistent with the guidance set forth in the Federal Acquisition Regulation ( FAR ) and/or FAR Supplements. Conveyance of any additional rights beyond limited or restricted rights in the Work requires Change Healthcare s express consent contained in a separate written agreement Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. No portion of this publication may be copied, reproduced, or incorporated into any other media without Change Healthcare s prior written consent. Produced in Cork, Ireland. Acknowledgments and Disclaimer: The Clinical Content is developed by Change Healthcare s clinical research staff which includes physicians, registered nurses, and other healthcare professionals. Many members of Change Healthcare s clinical staff hold advanced degrees and case management certification. The Clinical Content is reviewed and validated by a national panel of clinicians and medical experts, including those in community and academic practice settings, as well as within the managed care industry throughout the United States. The Clinical

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5 Contents Welcome to the Guide to Conducting Reviews... 8 Who Should Read this Guide... 9 Contacting Product Support... 9 Chapter 1 Using the Menu Bar About the Menu Bar Using the Work List Customizing the Work List Selecting a Review Selecting a Patient Finding Reviews in the Work List Deleting Reviews or Removing Reviews from the Work List Finding Patients Accessing the Find Patients Screen Finding Existing Patients Adding a New Patient Finding Reviews Accessing the Find Documents Screen Adding a New Review Viewing Open Items Accessing Help Chapter 2 Conducting Reviews About Primary Reviews Conducting a Primary Review Step 1: Add a New Review Adding a New Review First Finding a Patient First About the Review Screen Patient Tool Bar Document Tool Bar Navigation Pane Work Area Step 2: Select a Subset Finding a Subset by Keyword Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 5

6 Step 3: Enter Review Detail...43 Entering Review Detail Information...43 Selecting a Benchmark Length of Stay (LOS)...45 Saving a Review...46 Step 4: Evaluate Criteria...47 About Evaluating Criteria in a Decision Tree...48 About InterQual CriteriaView...53 About Evaluating Q&A Criteria...54 Review Manager Symbols, Notes, and Reviewer Comments...65 Evaluating Criteria for Level of Care Products...72 Evaluating Criteria for Behavioral Health Products...75 Steps for Evaluating Criteria in a Decision Tree...76 Steps for Evaluating Criteria in a Q&A Medical Review...77 Viewing Additional Criteria...79 Viewing and Selecting a Recommendation...80 Step 5: Record the Review Outcome and Results...82 About Review Outcome...82 About Review Status...83 How Review Outcome Triggers Review Status...84 Recording the Review Outcome...85 Recording Review Results...87 Viewing and Printing the Review Summary...88 Saving a Review...89 Conducting a Secondary Review...89 About Secondary Reviews...89 Conducting a Secondary Review...89 Simulating a Medical Review...91 Conducting an Appeal Review...93 About Appeal Reviews...93 Conducting an Appeal Review...93 Adding a New Review Initial Data Entry...94 Other Review-Related Features...95 Authorization...96 Insurance...96 Export...97 Show Full Subset...97 View Quality Indicator Checklist and View Transition Plan...97 Chapter 3 Using Quality Indicator Checklists and Transition Plans About Quality Indicator Checklists About Transition Plans Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 6

7 Adding a New Quality Indicator Checklist or Transition Plan Working with Quality Indicator Checklists Entering Quality Indicator Checklist Detail Evaluating Quality Indicators Initiating a Quality Review Viewing and/or Printing the Quality Indicator Checklist Summary Working with Transition Plans Entering Transition Plan Detail Evaluating Risk Factors for Readmission Evaluating Criteria for the Expected Discharge Level of Care Viewing and/or Printing a Transition Plan Summary Saving a Quality Indicator Checklist or Transition Plan Opening an Existing Quality Indicator Checklist or Transition Plan Marking a Quality Indicator Checklist or Transition Plan "Complete" Chapter 4 Managing Authorization Requests About Authorizations Requests Initiating an Authorization Request Entering Insurance Information Entering Requestor Information Entering Request-Specific Information Submitting an Authorization Request Working with Authorization Results About Authorization Status Viewing Authorization Results Editing Authorization Results Chapter 5 Exporting Reviews About Exporting Reviews Exporting a Review Working with Foreign Reviews Assigning a Foreign Review to Another Reviewer Viewing a Foreign Review Assigning a Foreign Review to a Local Patient Chapter 6 Generating InterQual CriteriaView Clinical Scenarios About InterQual CriteriaView Clinical Scenarios Generating InterQual CriteriaView Clinical Scenarios from a Review Viewing and Printing the Results Viewing Rules and Flags in Results Viewing Printed Results Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 7

8 Welcome to the Guide to Conducting Reviews This guide provides an overview of using InterQual Review Manager to conduct reviews with InterQual Criteria. This guide is organized as follows: Chapter 1: Using the Menu Bar This chapter introduces the Review Manager menu bar and some of the reviewrelated functions available from it, including Work List, Find (Patients or Documents), New (Review, Quality Indicator Checklist, or Transition Plan), Open Items, and Help. Chapter 2: Conducting Reviews This chapter introduces the stages of a review and provides detailed information on conducting reviews in Review Manager, including adding a new review, selecting a subset, entering review detail, evaluating criteria, and recording the review outcome and results. Chapter 3: Using Quality Indicator Checklists and Transition Plans This chapter introduces quality indicator checklists and transition plans and how to use them in Review Manager. Chapter 4: Managing Authorization Requests This chapter introduces authorization requests and how to specify information for and then submit an authorization request in Review Manager. It also addresses managing the authorization results sent by an insurer or other third party's authorization system. Chapter 5: Exporting Reviews This chapter introduces exporting reviews from Review Manager to another Review Manager system (or other application). It also addresses working with imported (that is, foreign) reviews. Chapter 6: Generating InterQual CriteriaView Clinical Scenarios. This chapter introduces the CriteriaView feature (Show Full Subset) that enables you to generate a list of clinical scenarios supported by InterQual Criteria for a specific procedure, imaging study, or other service. This view of the criteria can also be printed. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 8

9 Who Should Read this Guide This guide is intended for clinical reviewers who use Review Manager to conduct reviews with InterQual Criteria. Contacting Product Support You can contact Product Support in the following ways: Web Customerhub.changehealthcare.com Phone CRITERIA or Accessing Change Healthcare Customer Hub The Customer Hub (customerhub.changehealthcare.com) provides interactive support, answers to commonly asked questions, and links to other resources. For a user ID and password, on the Customer Hub login page, click the Need a User ID and Password? link or contact your Customer Hub site administrator. If you experience difficulty obtaining a user ID and password, contact Product Support. Obtaining Product Support If you experience difficulties using the software that you have licensed, please do the following before you contact Product Support: Consult the online Help and other documentation that accompanies the software to see whether your specific problem is addressed. Consult your internal help desk. If you still cannot resolve your problem, before contacting Product Support, please do the following to assist the Product Support representative in expediting the diagnosis and resolution of your problem: Record the nature of the problem and what you were doing just before the problem occurred. Determine the release number and the build number of the software that you are using. To obtain this information, on the menu bar, click Help and then click the About option. If possible, contact Product Support from in front of your workstation with the relevant application open. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 9

10 Chapter 1 Using the Menu Bar This chapter introduces the InterQual Review Manager menu bar and some of the review-related functions available from it, including: Work List Find New Patients Documents (for example, reviews) Automated Reviews (if licensed) Review Quality Indicator Checklist Transition Plan Open Items Help i Note: Because this guide focuses on conducting reviews, some menu bar functions are not addressed. For more information on these functions, (for example, Book View and Reports), refer to Review Manager Help. i Note: For more information on quality indicator checklists and transition plans, refer to "Using Quality Indicator Checklists and Transition Plans" on page 100 or Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 10

11 About the Menu Bar About the Menu Bar The menu bar, which is available at the top of any Review Manager screen, enables you to select Review Manager functions. i Note: Alliance Partners and Integrated Customers: The Work List, patient maintenance (for example, Find Patients on the menu bar), and reports are not available. Work List When you log in to Review Manager, the Work List automatically displays. At any time during your Review Manager session, you can access it by clicking the Work List button on the menu bar. Find New Patients Displays the Find Patients screen, which enables you to search for and/or add patients. Documents Displays the Find Documents screen, which enables you to search for reviews, quality indicator checklists, and transition plans. Automated Reviews Displays the Find Automated Reviews screen, which enables users with the appropriate security settings to assign automated reviews to a reviewer's Work List. Review Starts the process of adding a new review. Quality Indicator Checklist Starts the process of adding a new quality indicator checklist. Transition Plan Starts the process of adding a new transition plan. Book View View Subset Enables you to view InterQual Criteria. Print Book For Level of Care and Behavioral Health products, enables you to select subsets to include in a book that you can save and/or print. Open Items Enables you to view and navigate among currently open patients, documents associated with patients (for example, reviews), Book View items, and reports. Reports Enables you to generate a report. Help Enables you to view Review Manager Help, Guide to Conducting Reviews (this guide), InterQual Clinical Reference, Historical InterQual Clinical Reference (if available), and information about Review Manager, including version and build numbers, as well as contact information. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 11

12 About the Menu Bar Settings Enables you to customize the Work List, view your security settings, change your password, set a default location, and change the default number of subsets to display in the Find Subsets screen. Logout Ends your Review Manager session. i Note: The options that display in your menu bar will vary based on your assigned user security settings and the features (for example, quality indicator checklists and/or transition plans) your Review Manager system administrator enables in the Review Manager Administration Module. For more information, contact your Review Manager system administrator. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 12

13 Using the Work List Using the Work List The Work List is linked to your User ID. It displays a list of active items (for example, reviews) that are assigned to you or have been referred to you and require your attention during a specific time period. Additionally, the Work List displays reviews that you have referred for secondary review. When you log in to Review Manager, the Work List automatically displays. At any time during your session, you can access it by clicking the Work List button on the menu bar. The Work List includes several required columns, including Patient ID, Patient Name, and Description. It also includes several default columns that you can choose to display (or hide) by making selections in the Settings dialog box. You can also set the order in which the columns display. The Work List provides the following information: Patient ID The patient's unique identifier. Patient Name Patient's name displayed as last name, first name. Description Description of the document. For reviews, the name of the criteria product (for example, Acute Adult) and the subset (for example, Heart Failure). If no subset is selected, then "No Product Selected/No Subset Selected" displays. For quality indicator checklists and transition plans, the name of the criteria product and either "Quality Indicator Checklist" or "Transition Plan," as appropriate, displays. i Note: A description with the prefix "Foreign" indicates a foreign document (that is, a review imported from another Review Manager system. Due Date the item is due to be completed. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 13

14 Using the Work List i Note: If you conduct a review and specify a Next Review Date, then Review Manager will add a new review. This review will display on your Work List on the appropriate day. For example, on January 1, you conduct a review and specify a Next Review Date of January 4. If you view the Work List for: Today The review will display on your Work List starting January 4. Tomorrow The review will display on your Work List starting January 3. Next Week The review will display on your Work List immediately (because January 4 is within the next week). The Next Review Date displays in the Due column. To delete the review, for example, if the patient is discharged before the next review date, refer to "Deleting Reviews or Removing Reviews from the Work List" on page 20. Number Unique, sequential identification number that Review Manager assigns to a document the first time it is saved. Your system administrator can set a default prefix for review numbers. i Note: A document number with the prefix "F" (for example, F45) indicates a foreign document. For more information on foreign documents, refer to "Exporting Reviews" on page 127 or Review Manager Help. Status Status of the review, authorization communication, transaction, denial, discharge plan, quality indicator checklist, or transition plan in the Review Manager workflow. For example, In Primary (for reviews) or In Progress (for quality indicator checklists and transition plans. i Note: If a review has been submitted for an authorization request, then the current authorization status (for example, Auth Request Approved) is appended to the review status. For more information on authorization requests, refer to "Managing Authorization Requests" on page 113 or Review Manager Help. Assigned To Displays the name of the Review Manager user to whom the document has been assigned or referred. Priority Status User-entered document priority (for example, Critical), if any. Used for Reviews only. AR Criteria Status Criteria status of an automated review. Payment Type Displays the patient's payment type, which you can select or change in the Work List or Review Detail. Payment types can be customized in the Administration Module and by default include Commercial, Medicare, and Medicaid. i Note: If your organization licenses HL7 and the Visit Tracking feature is enabled in the Administration Module, then you can customize the Work List to include the Floor, Room, and Patient Type columns. For more information, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 14

15 Using the Work List Customizing the Work List You can customize the Work List by selecting columns to display (or hide) in the Customize Work List dialog box: 1. In the menu bar, click Settings. The Settings dialog box displays. 2. In the Work List section, click Customize. The Customize Work List dialog box displays. It has two lists side-by-side. The list on the left displays the columns available for the Work List and the list on the right displays the list of selected columns. Required fields appear dimmed and have an asterisk, indicating that you cannot remove them from the Selected fields list. 3. Select columns to include in the Work List by clicking the name in the Available fields list and clicking the arrow to move it to the Selected fields list. 4. If appropriate, remove columns from the Work List by clicking the field name in the Selected fields list and clicking the arrow to move it to the Available fields list. 5. Optionally, change the display order of the columns by clicking the column name and then clicking the up or down arrow. 6. Click Save. The Work List refreshes and displays your selections. i Note: At any time, you can return to the default list of columns and order by clicking Reset in the Settings dialog box. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 15

16 Using the Work List You can perform many tasks from the Work List. For example, while conducting reviews you might: Select a review You can view or edit a review. Select a patient You can select a patient and then: Select a review for the patient. Add a new review for the patient. Selecting a Review From the Work List, you can select a review to view or update. If your organization licenses InterQual AutoReview, you may have automated reviews that require your attention. Automated reviews include an AR Criteria Status field, which displays the criteria status. i Note: For information on how to select and edit automated reviews, see the Review Manager Help. 1. In the menu bar, click Work List. 2. In the Description column, click a review description (that is, the criteria product/subset). Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 16

17 Using the Work List If a criteria subset has already been selected, the Review Summary pane displays. You can view the Review Summary pane to see all information that relates to the review or you can click items on the navigation pane to view a specific component of the review. i Note: A pane is an area of a window. The Review screen comprises several panes, including the Review Summary pane, on the right, and the navigation pane, on the left, which enables users to navigate among the various Review screen panes. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 17

18 Using the Work List Selecting a Patient 1. In the menu bar, click Work List. 2. In the Patient Name column, click a patient's name. The Patient screen displays. You can perform many tasks from the Patient screen. For example, while conducting reviews you might: Select a review for the patient The Patient screen displays a list of reviews, completed and active, for the patient. You can select a review to view and/or edit. Add a new review for the patient. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 18

19 Using the Work List Selecting a Review for a patient 1. On the Patient screen's navigation pane, click Recent Patient Activity or Full Patient History as appropriate. i Note: Recent Patient Activity, by default, displays reviews from the past 14 days. Your Review Manager system administrator sets the number of days to include in recent activity in the Review Manager Administration Module. 2. To select a review to view and or edit, in the Description column, click a review description. Adding a New Review for the Patient 1. On the patient tool bar, point to Add and then click Review. The Review screen displays. 2. Complete the review process for the patient. i Note: For detailed information on conducting reviews, refer to "Conducting Reviews" on page 33 or Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 19

20 Using the Work List Finding Reviews in the Work List The Work List includes a filter feature that enables you to quickly find reviews that need your attention. You can filter based on information in any of the Work List columns. When you start typing in the Filter box, the Work List automatically filters items based on the text you enter. To find reviews in the Work List: 1. Enter text in the Filter box. A list of items displays. 2. Optionally, select an item from the Patient Name, Description or Assigned To field. i Note: The filter is cleared once you leave the Work List screen. Deleting Reviews or Removing Reviews from the Work List You might occasionally need to perform some housekeeping tasks to delete reviews or remove reviews from your Work List. For example: To delete a review with Pending Primary status To remove a review with In Primary status from your Work List To remove a review with Completed status from your Work List Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 20

21 Using the Work List Pending Primary A review with Pending Primary status might display on your Work List if: You conduct a review and specify a New Review Date. i Note: For more information, refer to the description of the Due column in the section "Using the Work List" on page 13. A Review Manager user with limited security enters preliminary information about a review and then assigns the review to you. i Note: For more information, refer to "Adding a New Review Initial Data Entry" on page 94. To delete a review with Pending Primary status (for example, if the patient is discharged before the next review date): 1. In the menu bar, click Work List. 2. Select the review you want to delete. The Review screen displays. 3. On the document tool bar, point to Options and then click Delete Review. 4. Click Yes. 5. Click OK. 6. Close the Patient screen. The review is deleted and removed from your Work List. In Primary If a review with In Primary status displays on your Work List, then you must record the review outcome. If you select the Approved outcome, then the completed review is removed from your Work List. i Note: For more information on review outcome and review status, refer to "Step 5: Record the Review Outcome and Results" on page 82. Completed In addition to active reviews, you might have reviews assigned to you that are completed by another reviewer. Once the other reviewer completes the review, it can be removed from your Work List in one of these ways. Automatically Remove a Review Your Review Manager system administrator can enable a setting in the Administration Module that automatically removes reviews that are completed by another reviewer. These reviews are removed from your Work List at the time they are completed; therefore, you do not need to manually remove them. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 21

22 Using the Work List Manually Remove a Review You can manually remove completed reviews directly from your Work List or by using the Delete function on the Options menu within a review. i Note: You can remove (not delete) a review that was completed by another reviewer and displays on your Work List with a review status of Completed. Do not delete reviews with a status of Completed; this will delete the review from the Review Manager database all together. From the Work List 1. In the menu bar, click Work List. 2. In the Work List, remove completed reviews as follows: To remove individual completed reviews, select the check box(es) to the left of the Patient ID field for the review. To remove all completed reviews, select the check box to the left of the Patient ID column. All completed reviews are selected. 3. Click Remove. 4. Click Yes in the confirmation message. i Note: For directions on how to remove reviews using the Delete function on the Options menu, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 22

23 Finding Patients Finding Patients Use the Find Patients screen to: Find existing patients Add a new patient i Note: If your organization licenses HL7, then you must not manually add new patients. To avoid entering duplicate patient information, you search for an existing patient before adding a new patient. You do this by entering search criteria, such as the patient ID, last name, first name, gender, date of birth, or any combination of these criteria. This enables you to narrow your search and limit the number of results that are returned. You can enter exact information; for example, you can search for a patient by entering the patient's last name, Smith. You can also search on partial information using a wildcard (*); for example, Sm* returns a list of patients whose last name starts with the letters "Sm," such as Smith, Smyth, and Smart. Additionally, you can enter search criteria in more than one field. Review Manager searches for patients that match all of the criteria entered; for example, if you enter last name Smith and first name Sue, then the search would return a list of patients that includes Sue Smith and excludes Bob Smith, Sue Clark, and Susan Smith. i Note: Enter search criteria, as appropriate, to limit the number of patients in the search results and to improve the search speed. If you enter too many search criteria, however, there might be no patients in the search results. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 23

24 Finding Patients Accessing the Find Patients Screen There are two ways to access the Find Patients Screen: To find or add a patient for a new review, on the menu bar, point to New and then click Review. To find or add a patient, on the menu bar, point to Find and then click Patients. Finding Existing Patients 1. From the Find Patients screen, enter search criteria, such as the patient ID or last name, to help you find specific patients. i Note: For more information on entering search criteria, refer to Review Manager Help. 2. Click Find Patients. The search results display in the lower section of the screen, below the search criteria. 3. Select a patient by clicking the patient's name in the Patient Name column. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 24

25 Finding Patients Adding a New Patient i Note: If your organization licenses HL7, then you must not manually add new patients as described here. If no existing patient is found, then add a new patient as follows: 1. In the menu bar, point to Find and then click Patients. 2. From the Find Patients screen, click Add Patient. The Patient Maintenance dialog box displays. If you searched for an existing patient, your search criteria display by default. 3. In the Patient Maintenance dialog box, enter information as appropriate. i Note: A red asterisk indicates a required field. If the Patient ID is unknown (for example, if the patient is a newborn), then check the Not Available check box. You can edit this patient's information later. When entering a Patient ID, specify an ID that is "permanent" and unique to the patient; for example, the patient's medical record number. Do not specify an ID that might change with each admission. Due to HIPAA regulations, do not use the patient's social security number as the Patient ID. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 25

26 Finding Patients Your Review Manager system administrator can also specify up to three custom patient fields. This information displays on the patient tool bar, located below the menu bar. 4. Optionally, add patient contact information. i Note: To add insurance information, you must save the patient information and then edit it. For information on adding patient contacts and insurance information, refer to Review Manager Help. 5. Click Save. i Note: By default, the patient's status is active. To deactivate a patient, clear the Active check box. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 26

27 Finding Reviews Finding Reviews The Find Documents screen enables you to find (that is, search for) one or more documents, including reviews, quality indicator checklists, and transition plans. You might want to find a review to: View a previously conducted review for a patient before adding a new review for the same patient Verify information View a review that does not appear on your Work List Audit a review Open a review for appeal You find reviews (and other documents) by entering search criteria, such as status, number, current outcome, criteria product/subset, the patient's last name, first name, ID, or gender, or any combination of these criteria. This enables you to narrow your search and limit the number of results that are returned. You can enter exact information; for example, you can search for a patient by entering the patient's last name, Smith. You can also search on partial information using a wildcard (*); for example, Sm* returns a list of patients whose last name starts with the letters "Sm," such as Smith, Smyth, and Smart. Additionally, you can enter search criteria in more than one field. Review Manager searches for patients that match all of the criteria entered; for example, if you enter last name Smith and first name Sue, then the search would return a list of patients that includes Sue Smith and excludes Bob Smith, Sue Clark, and Susan Smith. i Note: Enter search criteria, as appropriate, to limit the number of patients in the search results and to improve the search speed. If you enter too many search criteria, however, there might be no patients in the search results. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 27

28 Finding Reviews Accessing the Find Documents Screen 1. In the menu bar, point to Find and then click Documents. The Find Documents screen displays. 2. Enter search criteria in any of the following fields on the Find Documents screen: Status (for example, In Primary) Number Current Outcome (for example, Referred for Secondary) Product/Subset (for example, Acute Adult) or subset (for example, Heart Failure) Patient Information (for example, Last Name) Documents (Select one or more document types (for example, Reviews) to include in the search results). Select whether to include or exclude reviews with authorization requests, historical documents, and/or foreign documents 3. Optionally, click Advanced Search and enter additional search criteria, such as location; name of the assigned reviewer; date the review was modified, imported, or requested; facility; or provider. i Note: For more information on entering search criteria, refer to Review Manager Help. 4. Click Find Documents. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 28

29 Finding Reviews The search results display in the lower section of the screen. i Note: The search results in the Find Documents screen provide information similar to that in the Work List, with one notable exception: the Outcome (Status) column. If the review has an outcome, then this column displays the review outcome. If the review does not yet have an outcome, then this column displays the review status. In cases where the review is in appeal, this column displays both the outcome (for example, Not Approved) and the status (for example, Pending Appeal). 5. From the search results, select the Patient Name or Description. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 29

30 Adding a New Review Adding a New Review Conducting a review in Review Manager involves the following steps: 1. Add a new review. 2. Select a subset. 3. Enter review detail. 4. Evaluate criteria. 5. Record the review outcome and results. i Note: Depending on the criteria product you select, you evaluate criteria in step 4 either in decision-tree format or Q&A format. For more information, refer to "Step 4: Evaluate Criteria" on page 47 or to Review Manager Help. To begin the process of conducting a review, you add a new review: 1. On the menu bar, point to New and then click Review. The Select Patient dialog box displays. 2. Find an existing patient or add a new patient. The Review screen displays. i Note: For detailed information on finding existing patients or adding new patients, refer to " Finding Patients " on page 23 or to Review Manager Help. 3. Complete the review process for the patient. i Note: For detailed information on conducting reviews, refer to "Conducting Reviews" on page 33 or Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 30

31 Viewing Open Items Viewing Open Items The Open Items menu displays patients, documents associated with patients (for example, reviews), Book View items, and reports that are open in your current Review Manager session. You can use this feature to view and navigate among currently open items. For example, you might choose to work on several reviews simultaneously as you wait for additional patient information. Consider using the Open Items list as a checklist of open items (for example, reviews) that need to be saved and closed before logging out of Review Manager. 1. On the menu bar, point to Open Items. A list of open items displays. 2. From the drop-down list, select an item to view. If you point to a patient name, a list of open items associated with that patient displays. Click the item you want to view. i Note: Avoid opening too many items simultaneously. This can impact system performance. Additionally, if more than one reviewer opens and edits the same document (for example, a review), then only the edits of the first reviewer who saves the document are saved. If another reviewer attempts to save the document, then an error message displays; for example, "This review cannot be saved because it has been changed by another user since you opened it." Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 31

32 Accessing Help Accessing Help The Help menu provides the following resources: Resource Review Manager Help Guide to Conducting Reviews InterQual Clinical Reference Historical InterQual Clinical Reference About InterQual Review Manager Description A reference for using Review Manager features and functions. This guide. Information about InterQual Criteria and conducting reviews: Abbreviations & Symbols Drug List Criteria products information, including review process, bibliography, and clinical revisions i Note: Abbreviations & Symbols and the Drug List, which are part of the InterQual Clinical Reference, are also available directly from the Help menu. If your organization has access to InterQual Criteria from previous years, then the appropriate historical versions of InterQual Clinical Reference are also available. Information about Review Manager, including version and build numbers, as well as important contact information. To access these resources: 1. On the menu bar, point to Help. A list of options displays. 2. Click the appropriate option; for example, InterQual Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 32

33 Chapter 2 Conducting Reviews This chapter introduces the stages of a review and provides detailed information on conducting reviews in InterQual Review Manager, including adding a new review, selecting a subset, entering review detail, evaluating criteria, and recording the review outcome and results. About Primary Reviews A primary review is the first review a healthcare organization conducts to determine if a medical intervention or level of care is (or was) appropriate for a patient. i Note: Alliance Partners and Integrated Customers: The review workflow starts at Step 2: Select a subset. Conducting a Primary Review Conducting a review in Review Manager involves the following steps: 1. Add a new review. 2. Select a subset. 3. Enter review detail. 4. Evaluate criteria. 5. Record the review outcome and results. i Note: To perform all of the above steps, you must be assigned to the Conduct Primary Review activity. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 33

34 Step 1: Add a New Review Step 1: Add a New Review Before you conduct a review, you must add a new review. Because you conduct a review for a specific patient, adding a new review also involves finding a patient. There is more than one way to add a new review. For example, you can: Add a new review first and then find a patient for that review Find a patient first and then add a review for that patient i Note: You can also add a new review from a care folder or from an incoming admission. For more information, refer to Review Manager Help. Adding a New Review First To add a new review: 1. In the menu bar, point to New and then select Review. The Select Patient dialog box displays. 2. Find a patient or add a new patient. i Note: For detailed information on finding existing patients or adding new patients, refer to " Finding Patients " on page 23. Finding a Patient First To add a new review by finding a patient first: 1. In the menu bar, point to Find and then click Patients. The Find Patients screen displays. 2. Find an existing patient or add a new patient. i Note: For detailed information on finding existing patients or adding new patients, refer to " Finding Patients " on page 23. The Patient screen displays. 3. Point to Add and then select Review. The Review screen displays. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 34

35 About the Review Screen About the Review Screen The Review screen comprises the following: Patient tool bar Document tool bar Navigation pane Work area The menu bar is available at the top of any Review Manager screen. Patient Tool Bar The patient tool bar is located below the menu bar. On the left, the Add button enables you to add a review, quality indicator checklist, transition plan, or care folder for the current patient. To the right of the Add button, demographic information for the current patient displays, including Patient Name, Patient ID, Gender, Date of Birth and Date of Death. i Note: Your Review Manager system administrator can also specify up to three custom patient fields. On the far right, a button enables you to close the patient's information. (Note that this will also close the current review.) Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 35

36 About the Review Screen Document Tool Bar The document tool bar is located below the patient tool bar. On the left, information for the current document displays, including Review Number, Product, and Subset. i Note: For a new review, the review number on the document tool bar displays "New Review" until the review is saved for the first time. When you save the review, a review number is automatically assigned. On the right, depending on the type of document, where you are in the review process, and the features your Review Manager system administrator enables in the Review Manager Administration Module, the following display, as appropriate: Criteria status (for example, Criteria Not Met; Criteria Met; or, for Acute Adult or Pediatric condition-specific subsets, the level of care for which criteria were Met, for example, Acute Met) For products that evaluate criteria in Q&A format, the criteria status does not display on the document tool bar. Buttons that enable you to select a font size for viewing criteria and notes Buttons that enable you to save and/or close the document An Options button that enables you to perform other tasks Selecting a Font Size The Font Size buttons enable you to adjust the font size for viewing criteria and notes. Click the plus or minus buttons to increase or decrease the font size. Click the center button to restore the font size to 100%. The font size you select is saved as the new default (until you change it) and will be retained when you log out of Review Manager. Navigation Pane The navigation pane acts like a table of contents as you conduct a review and enables you to navigate the review workflow. As you conduct a review, the navigation pane adds appropriate items based on selections you make. For example, if you select the Acute Adult product and a criteria subset (for example, Heart Failure), the navigation pane displays Initial review (if enabled) and a list of episode days that apply to that subset. You use the navigation pane to navigate the review workflow: Generally speaking, you navigate from the top of the navigation pane to the bottom. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 36

37 About the Review Screen The blue shaded area indicates your current location in the review workflow. To navigate to a specific step in the review workflow, click the appropriate item on the navigation pane. For example, to return to the step that enables you to select Initial review or an episode day, click Select Day. To view the InterQual Clinical Reference for the selected product, click InterQual Clinical Reference at the bottom of the navigation pane. To navigate to the next step in the review workflow, click the arrow at the bottom of the navigation pane. i Note: When you move the pointer over an item that you can click, the pointer changes to a hand. Work Area The navigation pane controls the information that displays in the work area on the right side of the screen. You use the work area to make selections and to perform tasks in the Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 37

38 Step 2: Select a Subset review workflow. In this manual, note that pane is often used to refer to this area of the screen; for example, you evaluate and select criteria in the Criteria pane. Step 2: Select a Subset The next step in the workflow is to select a subset. i Note: Alliance Partners and Integrated Customers: The review workflow starts here. i Note: If you are assigned to the Historical Review activity, then you can also select a content version; for example, InterQual The following table summarizes Review Manager terms, such as product, and their content version, for example, InterQual Review Manager Term Product Category Description A collection of clinical information that helps evaluate medical needs through the continuum of patient care. For example, Acute Adult or Acute Pediatric. In Review Manager, categories organize the products. Examples of categories within Level of Care products include: Acute Adult Medical and Surgical Rehabilitation Acute Rehabilitation, Subacute Rehabilitation Examples of categories within Ambulatory Care Planning products include: Procedures (categories represent surgical specialties) Cardiology, General Surgery, Neurosurgery Imaging (categories represent body systems and include groups of imaging studies) Abdomen & Pelvis, Chest & Heart, Head & Neck Molecular Diagnostics (categories organize tests and families of tests) Hematology, Oncology Durable Medical Equipment General Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 38

39 Step 2: Select a Subset Review Manager Term Subcategory Subset Note: The name of the subset displays in the Subset Description column. Description In Review Manager, some categories have subcategories; for example, a productcategory-subcategory relationship is: Rehabilitation (product) Acute Rehabilitation (category) Adult Rehab and Pedi Rehab (subcategories) The intervention you consider for a review. Subsets identify a specific: Condition (Acute Adult and Pediatric) Body system, service, or specialty (other Level of Care subsets) Procedure (Procedures and SIM plus) Imaging study (Imaging) Drug (Specialty Rx Oncology and Specialty Rx Non-Oncology) Test or family of tests (Molecular Diagnostics) Device or equipment (Durable Medical Equipment) Diagnostic grouping (Specialty Referral) There is more than one way to find a subset. You can: Select a subset from a list of subsets you recently accessed. This enables you to quickly find the subsets you use most often. The list displays when you create a new review and, by default, includes the last 15 subsets you accessed. i Note: You can, optionally, change the default number of subsets that display in the Settings dialog box. See Review Manager Help for more information. Select a product, category, and, if applicable, a subcategory Enter search criteria for Keywords or Medical Codes. You can, optionally, limit a search by keyword or medical code to the latest content version for a subset. To do this, ensure that any product or content version selections are cleared (if necessary, click Clear Search) and the limit search to latest content version check box is selected. Search by keyword by entering a word found in the subset name. i Note: For more information, refer to Finding a Subset by Keyword. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 39

40 Step 2: Select a Subset Search by medical code by entering a code (that is, ICD codes, CPT, HCPCS code, or DEX Z-Code ). i Note: You can search by CPT code only if your organization licenses them. You can search by DEX Z-Code only if your organization licenses DEX Diagnostics Exchange and the InterQual Molecular Diagnostics product. To find a subset by selecting a product and category: 1. In the Subset pane, select a product. i Note: Keep in mind that the products that display depend on the criteria sets your organization licensed and installed. 2. Select a content version, if applicable. 3. Select a category. 4. If the category has subcategories, select a subcategory. In the lower section of the screen, Review Manager displays the subsets associated with each of the categories and/or subcategories. i Note: Some subsets have only a Clinical Evidence Summary; for example, Avian Influenza (CES Only). 5. To view a Clinical Evidence Summary, click the paper-clip icon in the CES column. You can save and/or print the document, as appropriate. 6. To view the note(s) associated with a subset, click the note icon in the Notes column to the left of the subset name. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 40

41 Step 2: Select a Subset The note displays. 7. Select a subset by clicking the subset name. The subset notes display. i Note: Most subsets have criteria to evaluate. If you select a subset that does not have criteria, you will see a Medical Review Note that directs you to refer the review for secondary medical review. If this occurs, continue from Step 5: Record the Review Outcome and Results. Finding a Subset by Keyword You may search for subsets by keyword as follows: For all products, you may enter a keyword found in the subset name. For Procedures, Imaging, and SIM plus Criteria, you can search for a subset using keywords including alternate names for the procedures such as RYGB for bariatric surgery. To find custom subsets, if applicable, enter the keyword "custom." You can, optionally, limit a search by keyword or medical code to the latest content version for a subset. To do this, ensure that any product or content version selections are cleared (if necessary, click Clear Search) and the limit search to latest content version check box is selected. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 41

42 Step 2: Select a Subset i Note: For more information on custom subsets, refer to the System Administrator's Guide. A keyword search returns a list of subsets containing words that exactly match the search keyword. Use a wildcard (*) to broaden the search; for example, transplant* returns subsets containing the words transplant, transplants, transplantation, and so on. If you enclose keywords in quotes, for example, "chest pain," the keyword search returns a list of subsets containing the phrase "chest pain." To broaden the search, omit the quotes. The keyword search returns a list of subsets in the following order: First, subsets containing the phrase "chest pain" Second, subsets containing both the word "chest" and the word "pain" Third, subsets containing either the word "chest" or the word "pain" i Note: For more information on finding a subset, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 42

43 Step 3: Enter Review Detail Step 3: Enter Review Detail After you select a subset, you can view the subset overview information and then enter review detail information. If the subset overview includes ICD codes, optionally, view the list of codes by clicking Show Codes. Hide the list by clicking Hide Codes. The Review Detail pane enables you to enter review detail information, including when the review was requested, location (a security setting), care folder (if enabled), requesting facility, requesting provider, assigned reviewer, and comments that provide supplemental information about the review. Entering Review Detail Information Enter review detail information. For example: Payment Type If appropriate, select or change the payment type. If the Payment Type column displays on your Work List, then any selection or change you make to the payment type here is reflected in the Work List. Review Request Date/Time Date and time that the review was requested. The system date and time automatically display. You can optionally change this information by entering a different date and time. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 43

44 Step 3: Enter Review Detail Location (required) Select a location. This is a security setting. The location you select often determines which Review Manager functions you can perform (for that particular location). i Note: Your Review Manager system administrator assigns each user to a specific set of locations for which that user can conduct reviews. If appropriate, you can set a default location for reviews in the Settings dialog box. See the Review Manager Help for more information. Care Folder (if enabled) Select the care folder that you want the review associated with, if any. If the admission is submitted through HL7 and the Care Folder field has a red asterisk (*), you are required to select a care folder. i Note: To add a new care folder, on the patient tool bar, move the pointer over Add and then click the type of care folder you want to add. Complete the information in the Add Care Folder dialog box. After you add a care folder, you can select it. i Note: For more information on care folders, refer to Review Manager Help. Facility Select the name of the facility requesting the review. Requesting Provider Select the name of the provider requesting the review. Assigned Reviewer (required) Select the name of the reviewer assigned to the review. ICD Codes Select an ICD code. Enter all or part of the diagnosis name or code in the data entry field and click Find. Select a diagnosis code from the list. Note that, if you are using historical content and both ICD-9 and ICD-10 codes are available, once you select one type of diagnosis code, the Lookup for the other type becomes disabled. Comments Optionally, enter more information for the next reviewer; for example, lab values. i Note: "This review was scheduled in advance..." in the Comments box indicates that Review Manager automatically created this review based on the Next Review Date of a prior review, as entered on the Review Outcome pane. Refer to "Step 5: Record the Review Outcome and Results" on page 82. Waiting for Info/Info Received Select the Waiting for Info check box to indicate that the review is awaiting further information. Selecting this check box disables the fields on the Primary Outcome pane until you either select the Info Received check box or clear the Waiting for Info check box. In most cases, you will also enter review detail information in fields that are productspecific; for example, Home Care Q&A has specific fields in which you can select requested service(s) and enter a value associated with the service, such as visit(s). You may also need to enter information in custom fields. Custom fields are specified by your Review Manager system administrator. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 44

45 Step 3: Enter Review Detail i Note: Although Location is the only required field for all reviews, the review detail information you enter is influenced by your reporting and other needs. For example, if you wish to generate reports for each facility, then users must select a facility whenever they conduct a review. Your Review Manager system administrator can show or hide several review-specific fields. Hidden fields do not display in the Review screen panes, including the Review Detail pane. For more information on entering review detail information, including length of stay, and additional, product-specific fields, refer to Review Manager Help. For more information on custom fields and showing or hiding fields, refer to the Review Manager System Administrator's Guide. Selecting a Benchmark Length of Stay (LOS) Available for select subsets, benchmark length of stay (LOS) information provides guidance around a typical length of stay for a condition. Benchmark LOS information is available for select Level of Care Acute Criteria subsets, and select inpatient procedures in the Ambulatory Care Planning Procedures subsets, and Medicare Procedures subsets. i Note: For Ambulatory Care Planning Procedures or Medicare Procedures subsets, you select a benchmark LOS value after you select a recommendation, see "Viewing and Selecting a Recommendation " on page 80 Viewing and selecting a benchmark LOS for Acute Criteria subsets: Subsets with a single diagnosis or procedure automatically have the benchmark LOS populated, so you don't need to select one. For subsets with multiple diagnoses or procedures, optionally, select a benchmark LOS as follows: 1. Click the benchmark icon in the navigation pane. The Benchmark LOS dialog box displays. 2. If appropriate, find a diagnosis or procedure by entering a partial or complete description in the Filter box. If necessary, use the navigation controls to view additional pages of results. The results include the type (InterQual and/or CMS GMLOS) diagnosis or procedure name, and the value. 3. Select a diagnosis or procedure from the list. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 45

46 Step 3: Enter Review Detail The Benchmark LOS dialog box closes and the benchmark value you selected appears in the navigation pane. Saving a Review After you enter review detail information and, if applicable, select a benchmark length of stay for Acute Criteria, you can continue with the review or save the information that you have entered and complete the review at a later time. Use the table below to determine your next step: If you... Want to continue with the review Do not want to continue with the review at this time Then... Click the appropriate item (for example Review Type) on the navigation pane (or, at the bottom of the navigation pane, click the Next arrow). Then, do one of the following: Go to "Step 4: Evaluate Criteria" on page 47. For more information on evaluating criteria, refer to "About Evaluating Criteria in a Decision Tree" on page 48 and "About Evaluating Q&A Criteria " on page 54. On the document tool bar, click Save to save the information you have entered and then click the Close button to close the review. i Note: The review now displays on your Work List. Keep in mind that, when a session times out, all unsaved work is lost. Therefore, it is important to save your work frequently, especially before a period of inactivity. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 46

47 Step 4: Evaluate Criteria Step 4: Evaluate Criteria The next step in the workflow is to evaluate criteria. Criteria are the clinical information the reviewer should consider when conducting reviews. Criteria comprise evidence-based clinical statements and rules for their application. Criteria are organized in one of two formats: Decision Tree In products that use this format, the workflow takes the form of a decision tree in which you can see all of the clinical statements and rules as you select criteria to conduct a review. Criteria includes indications, criteria points, rules, and notes. You can select as many criteria points as you like or as recommended by your organization. However, Review Manager requires only the minimum be selected (as required by the rules) in order for criteria to be met. This format is available for Level of Care (except Home Care Q&A), Behavioral Health (except Procedures (Q&A), SIM plus, and Care Planning Specialty Referral products. Question and Answer (Q&A) In products that use this format, criteria are presented in an interactive question-andanswer workflow that represents the same types of clinical statements and rules as those presented in a decision tree. As you conduct a medical review, your answers to questions about a patient's clinical presentation will lead you to the most appropriate drug, procedure, imaging study, test, service, or medical equipment. When you complete the medical review, the Recommendations pane displays the results from the medical review and allows you to choose among the recommendations, if any. Informational notes provide additional information. If the InterQual CriteriaView feature is available, it can help guide you through the Q&A criteria and reach a recommendation for a specific procedure, imaging study, or other service. If no recommendation is made, the Recommendations pane provides information that you can use to understand why your answers did not meet criteria for the requested recommendation. i Note: For detailed information about the CriteriaView feature, refer to "About InterQual CriteriaView" on page 53. The question-and-answer format is available for Level of Care: Home Care Q&A, Behavioral Health Procedures Q&A, Ambulatory Care Planning: Procedures, Imaging, Specialty Rx Oncology, Specialty Rx Non Oncology, Molecular Diagnostics, and Durable Medical Equipment products and the Medicare Procedures Powered by InterQual product. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 47

48 Step 4: Evaluate Criteria About Evaluating Criteria in a Decision Tree You navigate criteria that displays in decision tree format in the Criteria pane, which includes the following features. Criteria points Criteria points are clinical statements that refer to test results, medications, symptoms, findings, monitoring, medical management, functional status, and prescribed therapies. Criteria points support the reasons or indications; that is, they identify specific clinical elements that must be satisfied to justify the appropriateness of the intervention/service. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 48

49 Step 4: Evaluate Criteria Expanding and Collapsing Criteria Criteria points may be stand alone or be hierarchically embedded in a decision tree. You expand the decision tree by clicking the plus (+) sign to show the underlying criteria points. You collapse the decision tree by clicking the minus (-) sign. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 49

50 Step 4: Evaluate Criteria Rules Rules (for example, One, Both, and All) specify how many of the next-level criteria are required. Applying the rules ensures consistent and reliable criteria application. Simple All In Level of Care (excluding Outpatient Rehabilitation & Chiropractic) and Behavioral Health Criteria, where clinically appropriate, if you select a parent criteria point with a rule of All (or Both) that has only one level of underlying criteria points, then all of those underlying criteria points are automatically selected. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 50

51 Step 4: Evaluate Criteria Selectable Rule In Ambulatory Care Planning (Specialty Referral) Criteria, in some cases, the criteria point at the same level as the rule, in addition to the underlying criteria, must be applicable for the criteria to be met. This is called a selectable rule and occurs when both the criteria point at the same level as the rule and the next-level criteria are clinically true. Rule of One For the Rule of One, you can select only one underlying criteria point. If you select a second criteria point, an warning message displays. Criteria Status The criteria status (initially, Criteria Not Met) displays on the document tool bar. If you select criteria points that meet the criteria, the status changes to Criteria Met. In Acute Adult or Pediatric criteria subsets, if you select criteria points that meet criteria for a specific level of care, the status indicates that level of care (for example, Acute Met). i Note: If your organization licenses InterQual AutoReview and you are working with an automated review, you might see a status of Partial. Additionally, in some instances, criteria cannot be met, regardless of the number of criteria points you select. Secondary review is required. For more information on criteria status, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 51

52 Step 4: Evaluate Criteria Care Management Information Available for select subsets, Care Management Information is associated with a specific episode day and includes the following information: Admission Considerations Identifies the types of clinical findings that should be considered as part of an admission review. Expected Progress Provides an overall picture of what a care manager should expect in response to treatment, potential barriers to care, and suggested interventions. Care Facilitation Identifies when a plateau has been reached and provides direction to appropriate post acute levels of care. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 52

53 Step 4: Evaluate Criteria About InterQual CriteriaView In products that have criteria organized in Q&A format, CriteriaView is a feature that enables you to view the criteria that leads to a recommendation for a specific procedure, imaging study, or other service. To start a medical review, you select a specific recommendation(s) and then track that recommendation s availability as you answer questions about a patient s clinical presentation. If your selected recommendation(s) remains available, you are led to a recommendation(s) for that service. However, if a selected recommendation becomes unavailable, you will see immediately which answer caused it to become unavailable. Additionally, CriteriaView provides the option to view remaining criteria and answer additional questions for that recommendation. The Recommendations pane provides results that show why criteria for your selected recommendation were not met. CriteriaView Features CriteriaView includes these main features: Show/Hide Recommendation Turns CriteriaView features on/off in a medical review. You can show (or hide) recommendations so you can see the ones that are available for a selected subset. When you begin a medical review, all possible recommendations display for the selected subset. As you answer questions, the list of recommendations reduces based on your answers so that only recommendations that are still clinically appropriate remain. You can also select a specific recommendation(s) and track its availability as you answer questions. Additional Criteria If a tracked (selected) recommendation becomes unavailable based on your answers, you are presented with these options: Continue with Medical Review, Continue to Recommendations, and View additional criteria for (name of selected recommendation). The View additional criteria option displays all remaining criteria that leads to the selected recommendation and enables you to answer additional questions in order to capture as much patient information as possible for the medical review. Recommendations/Results When you complete the additional criteria section in the medical review, the Recommendations pane displays information that shows why the requested procedure, imaging study, or other service was not recommended. It provides a detailed comparison between your medical review selections and the path to the recommendation for each clinical scenario that leads to the recommendation. Review Summary Provides a complete clinical picture of the review. In addition to the initial medical review questions and answers, it includes the CriteriaView additional questions and answers as well as the Recommendations pane results that show why the requested service was not recommended. i Note: For more information about the Review Summary, refer to "Viewing and Printing the Review Summary" on page 88. Simulation (Secondary Review) Enables a secondary reviewer to replicate the Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 53

54 Step 4: Evaluate Criteria medical review conducted by a primary reviewer. Simulated medical reviews are not saved and do not replace the primary medical review. Instead, they allow the secondary reviewer to duplicate the primary reviewer's experience and try out alternate clinical paths. i Note: Simulation mode does not display additional criteria questions and answers that a primary reviewer may have completed as part of the medical review. For more information about the Simulation feature, refer to "Simulating a Medical Review" on page 91. CriteriaView Printed Clinical Scenarios In addition to the CriteriaView features in a medical review, CriteriaView also enables you to generate a list of all clinical scenarios supported by InterQual Criteria for a requested service. i Note: For directions on how to generate and print clinical scenarios, refer to "Generating InterQual CriteriaView Clinical Scenarios" on page 134. About Evaluating Q&A Criteria You navigate criteria that display in Q&A format in the Medical Review pane, which includes the following CriteriaView features: i Note: Availability of the CriteriaView feature depends on whether the CRITERIAVIEW activity is enabled for you in the Administration Module. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 54

55 Step 4: Evaluate Criteria Show/Hide Recommendations Turns CriteriaView features on/off in a medical review. You can show (or hide) recommendations so you can see the recommendations that are available for a selected subset. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 55

56 Step 4: Evaluate Criteria Select (Track) Recommendations Enables you to select specific recommendation(s) to track. As you complete the questions, you can see how your answers affect availability of the selected recommendation(s). i Note: If you choose the Home Care Q&A or Molecular Diagnostics product, and select service(s) in the Review Detail pane, then those service(s) are automatically selected in the Medical Review pane. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 56

57 Step 4: Evaluate Criteria Show Selected (Tracked) Recommendations Selecting the Show Selected Recommendations Only check box displays only recommendations that you selected to track. Available Recommendations As you answer questions, the list of recommendations reduces so that only clinically appropriate recommendations are available. Recommendations that are no longer available are crossed off the Recommendations list. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 57

58 Step 4: Evaluate Criteria Show Available Recommendations Selecting the Show Available Recommendations Only check box displays only recommendations that are still available. Answers Answers are in one of the following formats: Single response: Choose one (radio button). Multiple select: Choose all that apply (check boxes). Free text: Enter text to answer the question. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 58

59 Step 4: Evaluate Criteria Additional Criteria When one or more tracked (selected) recommendation(s) becomes unavailable based on your answers, you are presented with these additional options: Continue to Recommendations Displays the Recommendations pane. Continue with Medical Review Continues the medical review for a recommendation that is still available. View additional criteria Displays all remaining criteria that leads to the selected recommendation and enables you to answer additional questions. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 59

60 Step 4: Evaluate Criteria Rules Rules specify how to answer a question in order to follow the path to a recommendation. Rules appear as follows: For the initial medical review, rules display in brackets. For example, [ one] is a rule that might appear with a question that requires you to select more than one check box. For additional questions, which display when you choose to view additional criteria, rules display in a highlighted box below each question; for example, "If option Yes selected, then go to question 3", is a rule. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 60

61 Step 4: Evaluate Criteria Recommendations As you go through the medical review workflow, depending on how you answer a question, you are led to one of the following: Next question(s) in the medical review. Recommendation(s). Additional criteria (available only if CriteriaView is enabled). When a medical review leads to a recommendation, each recommendation might also have the following associated with it: Rules that specify how some recommended services should be used with each other or should be mutually exclusive. For example, a Mutually Exclusive (ME) rule indicates that you can select only one of the recommendations. Flags that provide explanatory text based on the results from the medical review. For example, a recommendation for a prescription medication might have an offlabel flag. Specialty Rx Oncology drugs that are recommended for off-label use are based on the NCCN Drugs and Biologics Compendium (NCCN Compendium ). These off-label recommendations include the NCCN Compendium rating. Additionally, a procedure might include a flag that recommends the setting (that is, inpatient or outpatient) where the procedure should take place. Values associated with the recommendation, such as hour(s) per day, time(s) per year, or visit(s). For example, a Home Physical Therapy recommendation might indicate a number of visits within a given time frame, such as 6 visits within 2 weeks. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 61

62 Step 4: Evaluate Criteria Benchmark length of stay (LOS) information, which provides guidance around a typical length of stay for a condition. This information is available for select inpatient procedures. Medical codes, which include ICD codes, CPT, HCPCS, and DEX Z-Code display in tabs. DEX Z-Codes are available for customers who have licensed DEX Diagnostics Exchange and the Molecular Diagnostics criteria product. A DEX Z-Code is a unique 5-character alpha-numeric code associated with a specific molecular diagnostic test. Recommendations Counter A counter in the navigation pane indicates the number of recommendations available for selection. Changing the Diagnosis in a Saved Review In some cases, you may need to modify a saved review that uses InterQual Criteria from a prior year and has ICD-9 codes selected for the recommendation. To change the recommendation to instead use ICD-10 codes, you must first remove the ICD-9 codes before adding any ICD-10 codes. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 62

63 Step 4: Evaluate Criteria Finding Medical Codes You may search for medical codes by entering the following in the Search field: A keyword found in the medical code description. A partial or complete code. You may also: Sort the list of medical codes in numerical order or alphabetical order by clicking Code or Description, as appropriate, in the column header. Move through the pages of codes by clicking the page numbers or the Next and Previous buttons. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 63

64 Step 4: Evaluate Criteria Additional Criteria Results If you chose to view additional criteria and answer additional questions in the medical review, the Recommendations pane provides information that shows why criteria for the selected recommendation were not met. It lists each clinical scenario that would lead to the selected recommendation, and provides a side-by-side comparison of your answers with the answers that would lead to the selected recommendation. A red triangle indicates a difference between the two answers. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 64

65 Step 4: Evaluate Criteria Review Manager Symbols, Notes, and Reviewer Comments Review Manager displays several symbols and notes associated with criteria organized in a decision tree and a medical review. Before evaluating criteria in either format, review and understand the symbols and notes that are associated with the criteria. Review Manager Symbols The following table summarizes the symbols that might display in Review Manager: Symbol Products Indicates... Plus/minus icon Check box/clear Check box/checked Check mark Check box in a Medical Review question Radio button in a Medical Review question Check box you use to select a recommendation Limited Evidence icon Red triangle on Recommendations pane Level of Care (except Home Care Q&A), Behavioral Health, (except Procedures Q&A) Ambulatory Care Planning Specialty Referral, and SIM plus. Level of Care (except Home Care Q&A), Behavioral Health, (except Procedures Q&A) Ambulatory Care Planning Specialty Referral, and SIM plus. Level of Care: Home Care Q&A, Behavioral Health Procedures (Q&A), Ambulatory Care Planning products, except Specialty Referral, Medicare Procedures Powered by InterQual. Ambulatory Care Planning products, except Specialty Referral. Ambulatory Care Planning products, except Specialty Referral. Criteria can be expanded or collapsed. Click the plus (+) sign to expand criteria. Click the minus (-) sign to collapse criteria. Check boxes used to make selections in decision-tree criteria. Check box(es) and radio buttons used to make selections in a Medical Review. Indicates that the recommendation is designated as limited evidence in this clinical scenario. On the Recommendations pane, indicates a difference between the reviewer's answers and the answers that lead to the selected recommendation. (Applies to medical reviews conducted using the CriteriaView feature.) Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 65

66 Step 4: Evaluate Criteria Symbol Products Indicates... Note icon (at the end of the criteria point) Red note icon (at the end of the criteria point) Quality Indicator icon (at the end of a criteria point) Transition Plan icon (at the end of a criteria point) Organizational policy icon (at the end of a criteria point) All products. Ambulatory Care Planning only. Level of Care Acute Adult and Pediatric only. Level of Care Acute Adult and Pediatric only. All products Informational notes are associated with the indication, criteria point, medical-review question, or recommendation. Click the icon to display the note. Mandatory note associated with the indication, criteria point, medical-review question, or recommendation. Click the icon to display the note. Quality Indicator notes are associated with the criteria point. If you select the criteria point, Change Healthcare recommends that you complete a quality indicator checklist for the patient. The criteria point often indicates that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning. If you select the criteria point, Change Healthcare recommends that you complete a transition plan for the patient. An organizational policy is associated with the indication, criteria point, or medical-review question. Your Review Manager system administrator uses the Review Manager Administration Module to enter organizational policies. View icon All products. Click to view notes, an organizational policy, or reviewer comments in a larger, separate window. Reviewer's Comments icon (at the front of the criteria point) Care Management Note Red urgent icon All products. Level of Care Acute Adult and Pediatric only. Ambulatory Care Planning only. Reviewer comments are associated with the criteria point Provides information that helps to drive quality care and ensure that the patient is progressing along the continuum of care. An urgent circumstance that does not require pre-authorization. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 66

67 Step 4: Evaluate Criteria Symbol Products Indicates... Secondary review icon Secondary medical review icon Benchmark LOS icon for: Level of Care Acute Criteria: Care Planning Procedures and Medicare Procedures Criteria: Electronic health record (EHR) data (automated reviews only) Criteria status (automated reviews only) Black urgent icon (at end of the criteria point) Warning icon etc. Behavioral Health Psychological Testing Procedure reviews only. All products Select Level of Care, Acute Criteria, Care Planning Procedures and Medicare Procedures Criteria. Available in automated reviews for select Level of Care, Acute Criteria. Select Level of Care, Acute Criteria. Level of Care: Acute Adult and Pediatric Behavioral Health: Adult and Geriatric, Child and Adolescent, and Substance Use Disorders. Ambulatory Care Planning Specialty Referral only. For the Behavioral Health procedure, a secondary review is required. Criteria point requires a secondary medical review. Click to view or select benchmark LOS values. Indicates that there is electronic health record (EHR) data available for a criteria point. Criteria point is an urgent circumstance and does not require pre-authorization. Selecting these criteria will not result in the criteria being met. A reason why this procedure, imaging study, surgery, specialty consultation, treatment/medication/monitoring, or equipment is requested. Green background All products. A custom subset. Notes Notes provide important information that assists the reviewer by providing reminders of best medical practice, new clinical knowledge, explanations of criteria rationale, definitions of medical terminology, and current literature references. A note icon indicates one or more notes are associated with a criteria point or medicalreview question. To view notes: Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 67

68 Step 4: Evaluate Criteria Click a note icon. The corresponding notes display in a separate window. Highlight the criteria point or medical-review question. The corresponding notes display in the lower section of the screen. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 68

69 Step 4: Evaluate Criteria Many notes cite the source of the criteria the evidence behind the InterQual content. To view citation information: Move the pointer over the reference number to see the citation description. Click the reference number to get the complete citation information. The Citation Detail dialog box displays the following: Bibliographic information Evidence-based medicine (EBM) classification (if classified) Abstract (if available) Definitions of all EBM classifications Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 69

70 Step 4: Evaluate Criteria i Note: For more information on note types, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 70

71 Step 4: Evaluate Criteria Reviewer Comments The Add Reviewer Comment button in the lower right corner of the Criteria pane or Medical Review pane displays the Reviewer Comments dialog box, which enables you to record comments specific to a particular review, criteria point, medical-review question, or patient. For example, you might want to include information that might be helpful to another reviewer, particularly when referring the review for secondary review, or you might want to focus the attention of another reviewer to a specific criteria point or medical-review response. i Note: If the CriteriaView feature is enabled and you choose the option to view additional criteria and answer questions, the Add Reviewer Comment feature is not available. i Note: The lower Review screen displays information such as notes, organizational policies, and reviewer comments. Comments are marked with the date and time; the reviewer's name may or may not display, depending on how it has been set in the Administration Module. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 71

72 Step 4: Evaluate Criteria Evaluating Criteria for Level of Care Products Level of Care Criteria support a care plan to transition the patient safely and economically from one level of care to another. Before you evaluate criteria for the Level of Care products, you must select a review type for the following: Long-Term Acute Care and Rehabilitation reviews Preadmission Admission Continued Stay Discharge Outpatient reviews Initial Ongoing Level of Care Acute Criteria InterQual Acute Level of Care Criteria provide support for determining the medical appropriateness of hospital admission, continued stay, and discharge. Acute Adult Criteria address the Observation, Acute, Intermediate, and Critical levels of care. Acute Pediatric Criteria include these levels of care and five additional levels of nursery care (Transitional Care, Newborn Level I, Special Care Level II, Neonatal Intensive Care Level III, and Neonatal Intensive Care Level IV). Adult criteria are for review of patients 18 years of age. Pediatric criteria are for review of patients < 18 years of age. Acute Criteria include these features: Initial Review Some subsets include Initial review criteria. Initial review criteria, which can optionally be hidden from display in the subset, are intended to be used as real-time decision support in the emergency department when observation or inpatient hospital level services are warranted. They help the reviewer determine whether a patient is appropriate for observation or inpatient admission at the time a decision to admit the patient is being made. Initial review criteria evaluate only data that is available at the time the decision is being made. This may include previously provided interventions or the results of laboratory, imaging, and other tests. Episode Days Acute Criteria subsets (except the Extended Stay subsets) comprise multiple episode days. You evaluate criteria for the appropriate episode day. Episode Day 1 is the first day in the episode of care for the patient, for that condition. The number of episode days varies based on the condition; most address common comorbidities and complicating factors associated with the primary condition. For example, the Heart Failure subset includes criteria through Episode Day 8. Keep in mind that, although the Acute Criteria subsets include criteria for each episode day, reviews do not need to be conducted on every episode day. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 72

73 Step 4: Evaluate Criteria Responder Criteria On the appropriate episode days, criteria may include one or more of the following responder-type criteria: Responder or Early Responder If met, indicate that the patient is clinically stable and that discharge is expected on that day. Partial responder If met, indicate that, for this condition and episode day, the patient is clinically appropriate for continued stay at this level of care. Non-responder If met, indicate that the patient requires continued stay; however, the episode days or level of care within the current condition-specific subset have been exhausted. Responder/Non-responder days are based on Length of Stay (LOS) data. In most condition-specific subsets, Responder criteria are introduced on Episode Day 2 and are labeled Early responder until the day after the LOS 25th percentile. Once Responder criteria are introduced, from that episode day on, there will always be Responder criteria and either Partial responder or Non-responder criteria. Non-responder days occur one day after the LOS 75th percentile. Redirection As you evaluate criteria, there are certain situations where you may be directed to a different subset. For example, in the case of Heart Failure, if Non-responder criteria indicate that the patient is not clinically stable for discharge, but the episode days or level of care within the current condition-specific subset have been exhausted, then you are directed to conduct a review using the Extended Stay subset or to refer for secondary review. i Note: When conducting Outpatient Rehabilitation & Chiropractic reviews, although you don't explicitly select a review type, you evaluate either Initial Review or Ongoing Review criteria. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 73

74 Step 4: Evaluate Criteria Subacute and SNF Criteria In Subacute and SNF Criteria, you select Preadmission or the appropriate episode week. i Note: The Medicare subset does not include episode weeks. To complete a review, you select the appropriate review type Preadmission, Admission, Continued Stay, and Discharge. Preadmission You conduct a review using the Preadmission criteria to determine the appropriateness of an admission prior to a planned admission or transfer to a specific level of care. Preadmission criteria include symptoms or findings of the patient s illness, clinical stability criteria, and why services may be precluded at a lower level of care. Episode Weeks An episode week consists of or spans a 7-day period. Each subset includes four episode weeks which represents the average length of stay in a subacute or SNF facility. Episode Week 1 contains criteria for an Admission review. It includes symptoms or findings of the patient s illness, clinical stability criteria, criteria indicating why the services may be precluded at a lower level of care and the interventions that are being provided. When conducting an admission review, use clinical information criteria derived from the first 48 hours of admission. Episode Weeks 2 and 3 represent continued stay. Episode Week 4 is considered extended stay and represents one week longer than the typical length of stay. Criteria may include one or more of the following responder-type criteria: Responder If met, indicate that the patient is clinically stable and that discharge is appropriate. Partial responder If met, indicate that the patient is clinically appropriate for continued stay at this level of care, for the designated week and condition. Non-responder If met, indicate that the patient may require continued stay; however, the weeks within the current subset and level of care have been exhausted. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 74

75 Step 4: Evaluate Criteria Evaluating Criteria for Behavioral Health Products Behavioral Health Criteria are designed to assess and support decisions about the medical necessity of admission to and continued stay at inpatient and ambulatory levels of care for the management of behavioral health disorders. You select a product (for example, Adult and Geriatric Psychiatry), a category and a subset. For all reviews, except Procedures and Procedures Q&A, you select a level of care; for example: Inpatient and then an episode day before you evaluate criteria. Levels of Care Levels of care in the criteria are listed in descending order of intensity of services and, depending on the subset, can include any of the following levels of care: Inpatient Inpatient Detoxification Inpatient Rehabilitation Observation Residential Crisis Program Residential Treatment Center Supervised Living Partial Hospital Program Home Care Intensive Community-Based Treatment Intensive Outpatient Program Outpatient Episode Days An episode day is a calendar day. The number of episode days varies by level of care. Episode Day 1 is the day of admission or initiation of treatment for the symptom the patient presents with. Episode Day 2 represents the second day in the episode of care and so on. When applying criteria to visits rather than days, the same logic applies. The first visit would be Episode Day 1. In some instances, the criteria are intended to be used for a range of days as opposed to a single day; for example, Episode Day 2 6. When there is a range of days, reviews are done using the same criteria for the range of days specified. Some levels of care include episode day s 2-x. In these instances, x represents an unspecified number of days. Symptom Type On the appropriate episode day, criteria may include one or more of the following Symptom Type criteria: Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 75

76 Step 4: Evaluate Criteria Symptom improved Criteria that indicate the patient is clinically stable. Discharge is expected on the day this criteria is selected. The Warning that the criteria are not met for the current level of care. symbol indicates Symptom improving or expected to improve Criteria that indicate the patient is clinically appropriate at that level of care, for the designated episode day and symptom. Symptom worsening Criteria that indicate that the patient s symptom is worsening and may require a more intensive level of care. The reviewer may select the recommended alternate level of care and continue the review. The Warning symbol indicates that the criteria are not met for the current level of care. Not clinically stable for discharge and exceeds length of stay expectation Criteria that indicate the patient may require continued stay; however, the episode days within the current level of care have been exhausted. The Warning symbol indicates that the criteria are not met. i Note: When an episode day includes more than one Symptom Type, only one Symptom Type can be met. Steps for Evaluating Criteria in a Decision Tree You evaluate and select criteria points from the Criteria pane. To evaluate and select criteria points: 1. To expand criteria, click the plus (+) sign. 2. Select one or more check boxes to select the corresponding criteria points. Check marks display to indicate your selections. If you select enough criteria points to satisfy criteria rules, the criteria status changes from Criteria Not Met to Criteria Met or, for Acute Adult or Pediatric condition-specific criteria subsets, the level of care for which the criteria were met; for example, Acute Met. Use the vertical scroll bar to see all of the criteria. i Note: In some instances, criteria cannot be met, regardless of the number of criteria points you select. Secondary review is required. 3. For selected or checked criteria points, read the notes, organizational policies, and/or reviewer's comments in the lower screen. Click a note or organizational policy icon. The corresponding note(s) or organization policy displays in a separate window. Highlight and/or select criteria points with note, organizational policy, or reviewer comments icons. The corresponding information displays in the lower section of the screen. For longer notes, organizational policies, or reviewer comments, you might need to use the scroll bar to view them in their entirety. To avoid having to Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 76

77 Step 4: Evaluate Criteria scroll, click the View icon. The corresponding information displays in a separate window. 4. Optionally, where available for select subsets, view care management information: A. If closed, click Care Management Information on the right side of the pane and then click the plus sign (+) to show the details. i Note: You can view the Care Management Information for all episode days by clicking Select Day in the navigation pane. B. Optionally, leave the Care Management Information details open as you evaluate criteria or close them by clicking the close (X) button. 5. Optionally, look up information in the InterQual Clinical Reference available from the navigation pane or the Review Manager Help menu. 6. To record supplemental information about a review, criteria point, or patient: A. Click an indication or criteria point. B. Click the Add Review Comment button in the lower right corner of the screen. The Reviewer Comments dialog box displays. C. Enter a comment. D. Click OK. 7. Click Save. Steps for Evaluating Criteria in a Q&A Medical Review You conduct a Q&A medical review in the Medical Review pane for: Level of Care, Home Care Q&A Behavioral Health, Procedures Q&A Ambulatory Care Planning products: Durable Medical Equipment Imaging Molecular Diagnostics Procedures Specialty Rx Non-Oncology Specialty RX Oncology Medicare Procedures powered by InterQual The medical review helps you determine the appropriateness of a requested service, drug, procedure, imaging study, test, or medical equipment. The medical review consists of answering a series of questions. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 77

78 Step 4: Evaluate Criteria The Recommendations pane displays the results from the medical review and allows you to choose among the recommendations, if any. i Note: If the CriteriaView feature is not enabled, skip steps 2 and 7 in the directions below. 1. On the Review screen navigation pane, click Medical Review. 2. Optionally, show and track recommendations, which display at the start of the questions as well as below each question, by doing any of the following: Show/Hide recommendations list By default, the recommendations list shows all possible recommendations available for the subset you selected. Click if you want to hide the recommendations list. Click to show the list again. Track specific recommendations From the list of available recommendations, select the check box(es) for the recommendation(s) you want to track. Tracked recommendations display in blue text. i Note: If you selected requested service(s) in the Review Detail pane, then those services are automatically selected in the Medical Review pane. Show Available Recommendations Only As you answer questions, the list of recommendations reduces so that only clinically appropriate recommendations are available. Optionally, hide recommendations that are no longer available by selecting the Show Available Recommendations Only check box on the navigation pane. Show Selected Recommendations Only To show only the recommendations that you selected to track, select the Show Selected Recommendations Only check box on the navigation pane. Tracked recommendations that subsequently become unavailable (based on your answers) will continue to display, but will be crossed off the list. (For example, indicates that this recommendation is no longer available.) i Note: You can, optionally, select both the Show Available Recommendations check box and the Show Selected Recommendations check box; however, if you do so, any recommendations you selected to track will only display as long as they are still available. 3. Answer the questions as they appear and follow any rules associated with the questions. Rules display within brackets (for example, [ One] is a rule) and specify how to answer a question. i Note: If you change your recommendation selection after you have started answering questions, a message alerts you that your action will change the Medical Review and asks if you want to start over. If the message appears, select Yes or No as appropriate. 4. For answers, read any notes, organizational policies, and/or reviewer's comments in the lower screen. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 78

79 Step 4: Evaluate Criteria 5. Click to continue with the medical review. 6. If the CriteriaView feature is not enabled and you reach the end of the medical review, clicking Next will automatically take you to the Recommendations pane. Continue with "Viewing and Selecting a Recommendation " on page If the CriteriaView feature is enabled and you reach the end of the available questions, continue with one of the following options: If the recommendation you want is still available, click Recommendation". and continue with "Viewing and Selecting a If one or more of your selected recommendations become unavailable, additional options are displayed. Review and select one of the options: If you select... Then... Next step... Continue to recommendations Continue with Medical Review View additional criteria (name of recommendation) The Recommendations pane appears. The remainder of the medical review questions appear. Additional questions appear. If a recommendation is made for an alternate service, continue with "Viewing and Selecting a Recommendation " on page 80. Otherwise, continue with "Step 5: Record the Review Outcome and Results" on page 82. Continue from Step 3 in the directions above to complete the medical review. Continue with "Viewing Additional Criteria". Viewing Additional Criteria When you view additional criteria for a recommendation, you are presented with a series of additional questions that lead to that recommendation. As you answer the questions, you can, optionally, skip a question if you do not have all the required information. Also, you are not required to answer the questions in any specific order; however, the rules may guide you to follow a certain path. Additionally, keep in mind that the additional questions may follow more than one path to the recommendation, so you may encounter the same question more than once. If this occurs, after you answer the initial question, any additional instances of that question are automatically populated with your answer. Answer the additional questions as follows: 1. Review the first question in the list to see which answer caused the recommendation to become unavailable. 2. Answer the questions using the rules that display in the highlighted box below each question as a guide. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 79

80 Step 4: Evaluate Criteria 3. As you answer the questions, you will reach a question that has one or more of the following rules associated with it. Review the table below and then decide your next step: If you select an answer with this rule:... Indicates that you can consider the medical review complete. Then: Click on the the results. link to review... selected recommendation cannot be reached; continue to answer questions (including skipped questions) Indicates that this answer does not meet criteria for this question. 1. Continue to answer questions (including any skipped questions) to capture as much clinical information as possible. 2. Click review the results. to All other selections do not lead to the selected recommendation; continue to answer questions (including skipped questions) Indicates that this answer does not meet criteria for this question. 1. Continue to answer questions (including any skipped questions) to capture as much clinical information as possible. 2. Click review the results. to 4. When the Recommendations pane appears, view the recommendation results. Viewing and Selecting a Recommendation When a medical review is complete, the results display in the Recommendations screen where you can: View and select a recommendation. View additional criteria results. Viewing and Selecting a Recommendation When a medical review leads to a recommendation, view and select a recommendation as follows: 1. View the recommendation details: To read any notes, click the Note icon (for example, click the Note icon to read an informational note). To see the ICD codes, CPT, HCPCS, and Z-Code identifiers that apply, click Show Codes. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 80

81 Step 4: Evaluate Criteria For Specialty Rx Oncology, view the NCCN Drugs & Biologics Compendium (NCCN Compendium ) rating for an off-label drug recommendation. To view the NCCN Compendium rating description, move the pointer over the rating number. To access the National Comprehensive Cancer Network (NCCN ) website, click NCCN Compendium Rating. i Note: For Level of Care: Home Care Q&A, the results might show both Recommended Services and Not Recommended Services. This occurs when you select two or more services and at least one service is recommended, and at least one service is not recommended. 2. To select a recommendation, select the check box. 3. If benchmark LOS information is available for an inpatient procedure, optionally, select a value: A. Click the benchmark icon. The Select Benchmark LOS dialog box displays. B. If appropriate, find a diagnosis or procedure by entering a partial or complete description in the Filter box. If necessary, use the navigation controls to view additional pages of results. C. Select a diagnosis or procedure from the list. The Benchmark LOS dialog box closes and the LOS value you selected appears in the Recommendations screen. 4. Optionally, select ICD codes as well as CPT, HCPCS codes, and Z-Code identifiers (available for Molecular Diagnostics Criteria subsets) as follows: Click the tab(s) for the code type you want to select (for example, CPT). Search by medical code or description. Alternately, use the page controls to move through the list of codes until you find the code(s) you want. To select a code, click Add. Selected codes display in the Selected Codes section. To clear a selected code, click Remove. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 81

82 Step 5: Record the Review Outcome and Results Step 5: Record the Review Outcome and Results After you have evaluated criteria in either a medical review or decision tree, you are ready to record the review outcome. About Review Outcome The review outcome reflects the reviewer's decision at each stage of the review. Evaluating criteria determines the criteria status; for example, you might see Criteria Not Met or Criteria Met; for Acute Adult or Pediatric criteria subsets, you might see the level of care for which criteria were met, for example, Acute Met. For Home Care Q & A criteria, you might see Criteria Partially Met. The criteria status, however, does not determine the outcome. Instead, reviewers select an outcome based on their clinical assessment. i Note: For more information on the Criteria Met status, refer to Review Manager Help. The outcomes that you can select in Review Manager depend on the stage of the review you are conducting (that is, primary review, secondary review, or appeal) and, in some cases, the criteria product you are using. The following review outcomes are available: Approved Available for primary and secondary reviews. Indicates that the review is approved, whether or not the criteria are met. Not Approved Available for secondary reviews only. Indicates that the review is not approved. Clinically Stable for Discharge Available for primary reviews only. Indicates that the patient is clinically stable for discharge. Referred for Secondary Available for primary and secondary reviews. Indicates you are referring the review for secondary review. Referred for Secondary - Medical Available for primary and secondary reviews. Indicates you are referring the review for a specific type of secondary review by medical staff. Request Withdrawn Available for primary reviews. Indicates that the patient or the provider has withdrawn the request for the review. Request Canceled Available for primary and secondary reviews. Indicates there is no longer a need to conduct the review because of something that happened during the review process; for example, a change in the patient's medical condition. Redirected Available for secondary reviews only. Indicates that the secondary reviewer has proposed an alternative treatment plan. Upheld Available for appeal reviews only. Indicates that the appeal review outcome concurs with the primary review outcome. Overturned Available for appeal reviews only. Indicates that the appeal review outcome rejects or overturns the primary review outcome. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 82

83 Step 5: Record the Review Outcome and Results The following review outcomes are available for primary reviews with Behavioral Health Criteria only: Discharge with no further treatment Indicates that the patient does not meet Alternate Level of Care criteria. Directed to New Criteria Subset A criteria note specifically directs the reviewer to another criteria subset. i Note: If you conduct an Adult Psychiatry, Geriatric Psychiatry, Adolescent Psychiatry, Child Psychiatry, or Substance Use Disorders & Drug Diagnosis concurrent review; select the Outpatient level of care; select the "Symptoms / Behavior improved / revolved" criteria point, then this review outcome is available. The following review outcomes are available for primary and secondary reviews with Retrospective Monitoring only: Appropriate Not Appropriate i Note: For additional information on review outcomes, refer to Review Manager Help. About Review Status Review status indicates the status of the review in the Review Manager workflow. It tracks how close the review is to being completed. The status is system generated; that is, triggered by the review outcome. If no review outcome has been selected, then the review status is either Pending Primary or In Primary. Review statuses are: Pending Primary Indicates that the review has been requested and that a data entry clerk or reviewer has entered preliminary information, but the assigned reviewer has not yet opened the review. After a reviewer has selected criteria and saved the review, the Pending Primary status ends. In Primary Indicates that the review is in primary review; that is, the assigned reviewer has initiated the review or opened a review request and the review is in progress. Pending Secondary Indicates that a primary review outcome has been completed and the review has been referred for secondary review. Pending Secondary - Medical Indicates that the primary review process has been completed and the review has been referred for a specific type of secondary review - by medical staff. Pending Appeal Indicates that the primary review process has been completed or the secondary review process resulted in a Not Approved outcome, and an appeal is in progress. Completed Indicates that the review process, at primary, secondary, or appeal level is complete. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 83

84 Step 5: Record the Review Outcome and Results i Note: Generally speaking, review status displays on the Work List (in the Status column). i Note: Reviews with a Completed status, however, do not display on your Work List unless you referred the review to another reviewer (for example, if you selected the Referred for Secondary review outcome) who then completed the review. How Review Outcome Triggers Review Status The review outcome you select reflects your clinical assessment. Then, this review outcome triggers which review status is recorded by InterQual Review Manager. For review stage(s): Selecting this review outcome: Automatically triggers this review status: Primary and secondary reviews Approved Completed Secondary reviews Not Approved Completed Primary reviews Clinically Stable for Discharge Completed Primary reviews Request Withdrawn Completed Primary and secondary reviews Primary and secondary reviews Primary and secondary reviews Primary reviews Primary reviews Request Cancelled Appropriate (Retrospective Monitoring only) Not Appropriate (Retrospective Monitoring only) Directed to New Criteria Subset (BH only) Discharge with no further treatment (BH only) Completed Completed Completed Completed Completed Secondary reviews Redirected Completed Appeal reviews Upheld Completed Appeal reviews Overturned Completed Primary and secondary reviews Primary and secondary reviews Referred for Secondary Referred for Secondary - Medical Pending Secondary Pending Secondary - Medical i Note: When the review has a completed status, the entire review is read-only (that is, it cannot be edited). Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 84

85 Step 5: Record the Review Outcome and Results Recording the Review Outcome To record the review outcome: 1. If not already opened, on the Review screen navigation pane, click Primary Outcome. The Primary Outcome displays. 2. Record the date and time that the review outcome was entered. If you leave this blank, the date and time the review is saved will be entered by default. To enter a date, click the calendar icon to select a date. 3. If appropriate, specify the next review date. i Note: The next review date enables you to schedule a follow-up review. Specify the date on which you want to post a new review to the assigned reviewer's Work List. When the reviewer opens the review, the Comments box will indicate that this review was scheduled in advance. 4. Optionally, select a priority from the Priority drop-down list. Reviews with higher priority should be addressed first. 5. If available, optionally, review the medical codes selected by the primary reviewer. Click Expand Section or Compress Section to expand/compress the information as necessary. Similarly, click Hide Codes or Show Codes to show/hide the codes. 6. In the Outcome drop-down list, select an outcome that represents the decision for this review. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 85

86 Step 5: Record the Review Outcome and Results For certain services, you might see information presented in a grid. For example, for Home Physical Therapy, the Services grid might display the following information: Service Name of the service(s) (for example, Physical Therapy). Requested Number of visits requested in the Review Detail pane. Recommended Number of visits supported by the criteria and displayed in the Recommendations pane following a medical review. 7. If appropriate, enter information in the Primary Reviewer Approved free text field. 8. If appropriate (for instance, if you selected either Referred for Secondary or Referred for Secondary-Medical), specify a secondary reviewer. i Note: If the secondary reviewer is an online user, then that user is assigned to the review. The review will display on both the referring reviewer's Work List and the secondary reviewer's Work List. If the secondary reviewer is an offline user, then the referring reviewer remains the assigned reviewer and the review remains on the primary reviewer's Work List. 10. Select the outcome reason(s) to convey more information to the next reviewer about the outcome. 11. Optionally, record any outcome comments. 12. On the document tool bar, click Save to save the information you have entered. i Note: After saving a review outcome, you can no longer modify the clinical content of the review. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 86

87 Step 5: Record the Review Outcome and Results Recording Review Results After you record the review outcome, you can record the results for a review that has criteria in a decision tree (you do not record the results for a medical review). Review results provide more information related to the review outcome. To record the review results: 1. On the Review screen navigation pane, click Review Results. The Review Results pane displays. 2. Complete the fields on this pane, as appropriate. i Note: For more specific information on recording review results, including a list of product-specific fields, refer to Review Manager Help. 3. On the document tool bar, click Save to save the information you have entered. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 87

88 Viewing and Printing the Review Summary Viewing and Printing the Review Summary You can use the Review Summary pane to view and/or print the Review Summary, which includes header information, review comments, review detail, benchmark length of stay (LOS) information, review outcome, authorization request or insurance information (if applicable), and criteria. If you are viewing an automated review, the review summary title displays as InterQual AutoReview Summary and includes electronic health record (EHR) data. i Note: For more information on InterQual AutoReview, refer to Review Manager Help. Each time you make a change to a review and then save the review, the Review Summary is updated to reflect the change. To view and/or print the Review Summary: 1. On the Review screen navigation pane, click Review Summary. The Review Summary pane displays. i Note: The Review Summary displays only those fields that have been completed. If you left a field blank, the field does not display. 2. To customize the Review Summary, click Print Options gear symbol to the right of Review Summary on the navigation pane and select print options, as appropriate. You could, for example, specify how much criteria displays or whether to display or hide comments, organizational polices, or notes. The options Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 88

89 Saving a Review you select are saved until you change them again, even if you exit Review Manager. The Review Summary print options display. Select Review Summary print options, as appropriate. The options you select are saved for subsequent reviews, even if you exit Review Manager. i Note: For more information on Review Summary print options, refer to Review Manager Help. 3. To print the Review Summary, click the printer icon to the right of Review Summary on the navigation pane. 4. On the document tool bar, click Save and then click the Close button to close the review. i Note: After you close a review and then open it again (for example, from the Work List), the Review Summary displays. Saving a Review To save a review, on the document tool bar, click Save. To close the review, click the Close button. Conducting a Secondary Review About Secondary Reviews A secondary review is any review performed after a primary review. A supervisor, specialist (therapist, nurse, etc.), or a physician may conduct a secondary review. Each organization determines the qualifications of the reviewers, as well as the extent to which a secondary review is performed in order to render a review outcome. Multiple secondary reviews are allowed. Any secondary reviewer may refer a review to another secondary reviewer. Secondary-medical denotes a special group of secondary reviewers who have been designated by their organization to conduct medical reviews. Conducting a Secondary Review Primary reviews may be referred for secondary review. Activities that secondary reviewers can perform on a review depend on whether the criteria are in decision-tree format or Q&A format. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 89

90 Conducting a Secondary Review Decision Tree Secondary reviewers can view the selected criteria points, but they cannot add or edit the selections. Q&A Secondary reviewers can view and, optionally, simulate the review conducted by the primary reviewer. Simulated medical reviews are not saved and do not replace the primary medical review. Additionally, secondary reviewers may not be Review Manager users (that is, "online" users); instead, they may receive the Review Summary by phone, fax, , or printed copy. In this case, they are "offline" users. When a primary reviewer refers a review to an offline user, the primary reviewer retains ownership of the review in Review Manager. As such, the primary reviewer must record the secondary outcome and related information on behalf of the offline user. Additionally, the primary reviewer can record identifying information (name, phone number, and so on) for the offline user in the Reviewer Comments dialog box. To conduct a secondary review: 1. In the menu bar, point to Find and then click Documents. The Find Documents screen displays. 2. Enter search criteria, such as Current Outcome (referred for Secondary or Referred for Secondary-Medical), to help you find specific reviews. 3. Optionally, click Advanced Search to enter additional search criteria. 4. Click Find Documents. 5. From the search results, locate the review for secondary review (either Referred for Secondary or Referred for Secondary-Medical). 6. Click the Description to open the review. The Review Summary pane displays. i Note: You can also conduct a secondary review by selecting the review from the Work List. For more information, refer to Review Manager Help. 7. Read the Review Summary. Optionally, read recorded review information by stepping through the Review screen panes. For example: Click the criteria subset name to view subset notes. Click Review Detail to view review requesting information. For reviews that have criteria in decision-tree format: Click one or more items under Criteria to view selected criteria. Click Primary Outcome to view the primary outcome and outcome reasons. For reviews that have criteria in Q&A format, optionally, simulate the medical review: Click Medical Review on the Review screen navigation pane. Simulate the medical review (See "Simulating a Medical Review" on page 91). Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 90

91 Conducting a Secondary Review 8. On the navigation pane, click Secondary Outcome and record an outcome. 9. For Home Care Q&A, review the information in the Services & Visits grid. Then, optionally, enter the number of visits you approve for services in the Secondary Reviewer Approved section of the grid. 10. If appropriate, specify the procedure, imaging study, or other service as well as medical codes that you are authorizing on the secondary review. i Note: To see the medical code information more clearly, click Expand Section or Compress Section to expand/compress the information as necessary. Similarly, click Hide Codes or Show Codes to hide/show codes. 11. On the document tool bar, click Save and then click the Close button to close the review. i Note: Once the secondary reviewer completes the review, it displays on the Work List of the reviewer who referred the review. The review status is Completed. Simulating a Medical Review i Note: When in simulation mode, all items on the navigation pane, except those related to the simulation feature, are disabled. These options are enabled when you exit simulation mode. Simulating a medical review enables a secondary reviewer to replicate the medical review conducted by a primary reviewer. Simulated medical reviews are not saved and do not replace the primary medical review; instead, they allow the secondary reviewer to duplicate the primary reviewer experience and try out alternate clinical paths. i Note: Simulation mode does not display additional criteria questions and answers that a primary reviewer may have completed as part of the medical review. 1. Click. 2. Optionally, view the primary reviewer's answers to the questions. 3. Optionally, do any of the following: Track availability of specific recommendations From the list of available recommendations, select the check box(es) for the recommendation(s) you want to track. Tracked recommendations display in blue text. Optionally, hide the list of available recommendations by clicking. Click to display the list again. Show Available Recommendations Only As you answer questions, the list of recommendations reduces so that only clinically appropriate recommendations are available. To hide unavailable recommendations, select the Show Available Recommendations Only check box on the navigation pane. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 91

92 Conducting a Secondary Review Show Selected Recommendations Only To show only the recommendations that you want to track, select the Show Selected Recommendations Only check box on the navigation pane. Tracked recommendations that subsequently become unavailable (based on your answers) will continue to display, but will be crossed off the list. (For example, indicates that this recommendation is no longer available.) 4. Answer the questions as they appear and follow any rules associated with the questions. Rules specify how to answer questions in order to get to the next question. Rules display with brackets (for example, [ One] is a rule. i Note: At any time, you can click to leave simulation mode. 5. For answers, read any notes, organizational policies, and/or reviewer's comments in the lower screen. 6. Click Next to continue with the medical review. 7. At any time, optionally, reset the primary reviewer's answers by clicking Restore Primary Reviewer Answers. 8. Click to exit simulation mode and record the outcome. 9. Record the outcome by continuing with Step 9 in topic "Conducting a Secondary Review" on page 89. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 92

93 Conducting an Appeal Review Conducting an Appeal Review About Appeal Reviews At the request of the patient, provider, physician or facility, a review determination may be reconsidered. An appeal is a formal request (usually in writing) that a decision be reviewed and reconsidered for a change in the decision outcome. A review may be opened for appeal, and the appeal outcome and reasons can be recorded. Reviews for appeal will have been referred for secondary review and will not have a secondary outcome of approved. The appeals reviewer or an appeals board reads through all components of the review and then, assigns an appeal review outcome to be recorded in Review Manager. Conducting an Appeal Review Review Manager does not automatically generate any system messages or generate a Work List entry to indicate that you need to complete an appeal review. Rather, you (or an "offline" user) will be notified in writing or by phone that an appeal has been requested. To open an appeal, the review must have the Secondary Outcome of Not Approved. Reviews for which you record an appeal outcome will have a Completed status. To conduct an appeal review, do the following: 1. In the menu bar, move point to Find and then click Documents. The Find Documents screen displays. 2. Enter search criteria, such as Current Outcome (Not Approved), to help you find specific reviews. 3. Optionally, click Advanced Search to enter additional search criteria. 4. Click Find Documents. 5. Identify a review for which an appeal has been requested. 6. To select the review, in the Description column, click the review description. The Review Summary pane displays. 7. Read the Review Summary. Optionally, read recorded review information by stepping through the Review screen panes. For example: Click the criteria subset name to view subset notes. Click Review Detail to view review requesting information. For decision-tree criteria, click one or more items under Criteria to view selected criteria. For Q&A criteria, click one or more items under Guidelines to view answers to medical-review questions and/or a recommended procedure, imaging study, medical equipment, test, drug, or drug regimen. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 93

94 Adding a New Review Initial Data Entry Click Primary Outcome to view the primary outcome and outcome reasons. Click Secondary Outcome to view secondary outcome and outcome reasons. 8. On the document tool bar, move the pointer over Options and then click Open for Appeal. 9. The Appeal Outcome pane displays. 10. Record the appeal date and time, outcome, reviewer, reasons, and any comments. 11. On the document tool bar, click Save and then click the Close button to close the review. Adding a New Review Initial Data Entry Some Review Manager users might have limited security that allows them to enter only preliminary information about the review; for example, you might be able to enter information about the patient, assign the review to a reviewer, and select a subset, but you cannot evaluate and select criteria. Once this preliminary information is saved, the review displays on the assigned reviewer's Work List. To complete the initial data entry, do the following: 1. On the menu bar, point to New and then click Review. The Select Patient dialog box displays. 2. Find an existing patient or add a new patient. 3. Select a subset, as appropriate. 4. On the Review screen Review Request pane, enter Review Detail information, including the assigned reviewer. 5. On the document tool bar, click Save and then click the Close button to close the review. i Note: For more information on finding an existing patient or adding a new patient, refer to "Step 1: Add a New Review" on page 34. For more information on entering review detail information, refer to "Step 3: Enter Review Detail" on page 43. For more information on selecting a subset, refer to Step 2: Select a Subset. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 94

95 Other Review-Related Features Other Review-Related Features The following review-related features might also display on the navigation pane: Authorization Insurance Export Show Full Subset Reference Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 95

96 Other Review-Related Features Authorization You use the Authorization pane to initiate, submit, and manage authorization requests. i Note: Your Review Manager system administrator must enable authorization requests in the Review Manager Administration Module. i Note: For more information on authorization requests, refer to "Managing Authorization Requests" on page 113 or Review Manager Help. Insurance You use the Insurance pane to specify insurance information for the review. i Note: The Insurance pane is available only if your Review Manager system administrator enables it in the Review Manager Administration Module (and does not enable authorization requests). To specify insurance information: 1. On the navigation pane, click Insurance. The Insurance pane displays. 2. Under Insurance Details, select a Subscriber ID/Policy. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 96

97 Other Review-Related Features Insurer and subscriber information displays. 3. Edit the patient, add a subscriber, or add the member to an existing subscriber, as needed. i Note: For more information on specifying insurance information, refer to "Managing Authorization Requests" on page 113 or Review Manager Help. Export You use the Export pane to export a review (or other document) to another system. i Note: Your Review Manager system administrator must enable exporting reviews (and other documents) in the Review Manager Administration Module. i Note: For more information on exporting reviews, refer to "Exporting Reviews" on page 127 or Review Manager help. Show Full Subset You use Show Full Subset to access the CriteriaView feature that enables you to generate a list of clinical scenarios supported by InterQual Criteria for a specific procedure, imaging study, or other service. This view of the criteria can also be printed. i Note: : For more information on generating clinical scenarios, refer to "Generating InterQual CriteriaView Clinical Scenarios" on page 134 or Review Manager Help. View Quality Indicator Checklist and View Transition Plan A Quality Indicator icon indicates that quality measures are associated with a criteria point. A criteria point with a Transition Plan icon often indicates that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning. i Note: Quality Indicator and Transition Plan icons are available in Acute Adult and Pediatric Criteria only. If, while conducting a review, you select one or more of these criteria points, then you can view the quality indicator checklist and/or transition plan from within the review. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 97

98 Other Review-Related Features To view the quality indicator checklist, on the navigation pane, click View Quality Indicator Checklist. The quality indicator checklist displays. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 98

99 Other Review-Related Features To view the transition plan, on the navigation pane, under View Transition Plan, click Risk factors for readmission or Expected Discharge Level of Care, as appropriate. The transition plan displays. This information is read-only; Change Healthcare recommends that you also complete an interactive quality indicator checklist and/or transition plan, as appropriate, for the patient. i Note: Your Review Manager system administrator must enable the quality indicator checklist and/or transition plan workflow in the Review Manager Administration Module. For more information on quality indicator checklists and transition plans, refer to "Using Quality Indicator Checklists and Transition Plans" on page 100 or Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 99

100 Chapter 3 Using Quality Indicator Checklists and Transition Plans This chapter introduces quality indicator checklists and transition plans and how to use them in InterQual Review Manager. About Quality Indicator Checklists A quality indicator checklist enables you to interactively manage and report on National Quality Forum (NQF) inpatient quality measures independent of an InterQual Level of Care review. In Level of Care Acute Adult and Pediatric Criteria, a Quality Indicator icon indicates that quality measures are associated with a criteria point. If, while conducting a review, you select one or more of these criteria points, a message displays recommending that you complete a quality indicator checklist for the patient. Quality indicator checklists are patient-specific and are associated with an episode of care. There can be only one quality indicator checklist in progress for a patient at any given time. About Transition Plans A transition plan is a comprehensive discharge planning guideline that enables you to interactively manage and report on the discharge plan throughout the episode of care. It provides a framework for identifying discharge needs and outlines the interventions necessary to ensure continuity of quality patient care. Evidence has demonstrated that attention to transitioning care from one setting to another can significantly improve outcomes, impact quality of care, and reduce readmissions. In Level of Care Acute Adult and Pediatric Criteria, a criteria point with a Transition Plan icon often indicates that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning. If, while conducting a review, you select one or more of these criteria points, a message displays recommending that you complete a transition plan for the patient. Transition plans are patient-specific and are associated with an episode of care. There can be only one transition plan in progress for a patient at any given time. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 100

101 Adding a New Quality Indicator Checklist or Transition Plan Adding a New Quality Indicator Checklist or Transition Plan If your Review Manager system administrator enables automatic creation of quality indicator checklists and/or transition plans in the Review Manager Administration Module, and if, while conducting a review, you select the appropriate criteria, then Review Manager automatically adds a new quality indicator checklist and/or transition plan for the patient to your Work List. Otherwise, to add a new quality indicator checklist or transition plan: 1. In the menu bar, move the pointer over New and then click Review. The Find Patients dialog box displays. 2. Find a patient. i Note: For detailed information on finding existing patients, refer to "Finding Patients" on page 20. The Review screen displays. 3. From the subset pane, select a product. Under InterQual Products, select either LOC: Acute Adult or LOC: Acute Pediatric. Quality indicator checklists are available for the following products: Level of Care Acute Adult Criteria Level of Care Acute Pediatric Criteria Transition plans are available for the following products: Level of Care Acute Adult Criteria Level of Care Acute Pediatric Criteria Level of Care Long-Term Acute Care Criteria Level of Care Rehabilitation Criteria Level of Care Subacute & SNF Criteria 4. Under Categories, select Quality Indicator Checklist or Transition Plan Category. 5. Under Subset Description, click Quality Indicator Checklist or Transition Plan. i Note: There can be only one quality indicator checklist and only one transition plan in progress for a patient at any given time. If a quality indicator checklist or transition plan for the patient is already in progress, then a message displays prompting you to open the existing quality indicator checklist or transition plan. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 101

102 Adding a New Quality Indicator Checklist or Transition Plan The Quality Indicator Checklist or Transition Plan screen displays. Other Methods of Adding a New Quality Indicator Checklist or Transition Plan If your Review Manager system administrator enables the quality indicator checklist and/or transition plan workflow in the Review Manager Administration Module, then you can also add a new quality indicator checklist or transition plan as follows: On the menu bar, move the pointer over New and then click Quality Indicator Checklist or Transition Plan From the Patient screen From a care folder (if enabled) i Note: For more information, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 102

103 Working with Quality Indicator Checklists Working with Quality Indicator Checklists Working with quality indicator checklists in Review Manager involves: Entering quality indicator checklist detail. Evaluating quality indicators. Initiating a quality review, if appropriate. Viewing and/or printing the Quality Indicator Checklist Summary. Entering Quality Indicator Checklist Detail The Quality Indicator Checklist Detail pane enables you to enter quality indicator checklist detail information, including the request date and time, location (a security setting), care folder (if enabled), requesting facility, requesting provider, assigned reviewer, priority, admit date, discharge date, and comments. Your Review Manager system administrator can also specify up to three custom fields. To enter quality indicator checklist detail: 1. On the Quality Indicator Checklist screen navigation pane, click Quality Indicator Checklist Detail. The Quality Indicator Checklist Detail pane displays. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 103

104 Working with Quality Indicator Checklists i Note: Your Review Manager system administrator can show or hide several quality indicator checklist-specific fields. Hidden fields do not display in the Quality Indicator Checklist screen panes, including the Quality Indicator Checklist Detail pane. 2. Enter quality indicator checklist detail information. i Note: Quality indicator checklist detail information is similar to review detail information. For more information, refer to "Entering Review Detail Information" on page 43 or Review Manager Help. Evaluating Quality Indicators The next step in the workflow is to evaluate quality indicators. Quality indicators are organized in a decision tree with clinical conditions at the top level and quality indicators at the next level. You expand the decision tree, if necessary, by clicking the plus (+) sign. You collapse the decision tree by clicking the minus (-) sign. To evaluate quality indicators: 1. On the navigation pane, under Quality Indicator Checklist, click Quality Indicators or a clinical condition (for example, Substance Use). The Quality Indicator Checklist pane displays. 2. Expand or collapse criteria, as needed. 3. For each quality indicator, indicate whether it was completed by selecting Yes, No, or N/A. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 104

105 Working with Quality Indicator Checklists 4. For selected indicators, read the notes, organizational policies, and/or reviewer's comments in the lower screen. 5. Add reviewer comments, as needed. Initiating a Quality Review You may initiate a request for a quality review (for example, a follow-up by the director of Quality Assurance) when the documentation for a quality indicator checklist is incomplete. To initiate a quality review: 1. On the navigation pane, click Quality Review. The Quality Review pane displays. 2. Select Flag for Quality Review. 3. Optionally, use the Quality Review Comments box to record supplemental information. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 105

106 Working with Quality Indicator Checklists Viewing and/or Printing the Quality Indicator Checklist Summary You can use the Quality Indicator Checklist Summary pane to view and/or print the Quality Indicator Checklist summary, which includes header information, comments, quality indicator checklist detail, quality review information, and quality indicators. To view and/or print the Quality Indicator Checklist Summary: 1. On the Quality Indicator Checklist screen navigation pane, click Quality Indicator Checklist Summary. The Quality Indicator Checklist Summary pane displays. 2. To print the Quality Indicator Checklist Summary, click Print to the right of Quality Indicator Checklist Summary on the navigation pane. i Note: After you save and close a quality indicator checklist and then open it again (for example, from the Work List), the Quality Indicator Checklist Summary displays. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 106

107 Working with Transition Plans Working with Transition Plans Working with transition plans in Review Manager involves: Entering transition plan detail. Evaluating risk factors for readmission, if applicable. i Note: Risk factors for readmission are available in transition plans for Level of Care Acute Adult and Pediatric Criteria only. Evaluating criteria for the expected discharge level of care. Viewing and/or printing the Transition Plan Summary. Entering Transition Plan Detail The Transition Plan Detail pane enables you to enter transition plan detail information, including the request date and time, location (a security setting), care folder, requesting facility, requesting provider, assigned reviewer, priority, admit date, discharge date, length-of-stay data, medical codes, and comments. Your Review Manager system administrator can also specify up to three custom fields. To enter transition plan detail: 1. On the Transition Plan screen navigation pane, click Transition Plan Detail. The Transition Plan Detail pane displays. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 107

108 Working with Transition Plans i Note: Your Review Manager system administrator can show or hide several transition plan-specific fields. Hidden fields to not display in the Transition Plan screen panes, including the Transition Plan Detail pane. 2. Enter transition plan detail information. i Note: Transition plan detail information is similar to review detail information. For more information, refer to "Entering Review Detail Information" on page 43 or Review Manager Help. Evaluating Risk Factors for Readmission The next step in the workflow is to evaluate risk factors for readmission. i Note: Risk factors for readmission are available in transition plans for Level of Care Acute Adult and Pediatric Criteria only. Risk factors for readmission, like review criteria, are organized in a decision tree. You expand the decision tree by clicking the plus (+) sign. You collapse the decision tree by clicking the minus (-) sign. To evaluate risk factors for readmission: 1. On the navigation pane, under Transition Plan, click Risk factors for readmission. The Transition Plan pane (with Risk factors for readmission) displays. 2. Expand or collapse criteria, as needed. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 108

109 Working with Transition Plans 3. Select one or more check boxes to select the corresponding risk factors. 4. Read notes, organizational policies, and reviewer comments, if applicable. 5. Add reviewer comments, as needed. Evaluating Criteria for the Expected Discharge Level of Care The next step in the workflow is to evaluate criteria for the expected discharge level of care. These criteria, like review criteria, are organized in a nest decision tree. You expand the decision tree by clicking the plus (+) sign. You collapse the decision tree by clicking the minus (-) sign. To evaluate criteria for the expected discharge level of care: 1. On the navigation pane, under Transition Plan, click Expected Discharge Level of Care or a specific level of care (for example, Home Care). The Transition Plan pane (with criteria for the expected discharge level of care) displays. 2. Expand or collapse criteria, as needed. 3. Select one or more check boxes to select the corresponding risk factors. 4. Read notes, organizational policies, and reviewer comments, if applicable. 5. Add reviewer comments, as needed. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 109

110 Saving a Quality Indicator Checklist or Transition Plan Viewing and/or Printing a Transition Plan Summary You can use the Transition Plan Summary pane to view and/or print the Transition Plan Summary, which includes header information, transition plan detail, comments, and criteria. To view and/or print the Transition Plan Summary: 1. On the Transition Plan screen navigation pane, click Transition Plan Summary. The Transition Plan Summary pane displays. 2. To customize the Transition Plan Summary, click Display/Print Options. 3. To print the Transition Plan Summary, click the printer icon to the right of Transition Plan Summary on the navigation pane. i Note: After you save and close a transition plan and then open it again (for example, from the Work List), the Transition Plan Summary displays. Saving a Quality Indicator Checklist or Transition Plan To save a quality indicator checklist or transition plan, on the document tool bar, click Save. To close a quality indicator checklist or transition plan, click the Close button. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 110

111 Opening an Existing Quality Indicator Checklist or Transition Plan Opening an Existing Quality Indicator Checklist or Transition Plan There is more than one way to open an existing quality indicator checklist or transition plan. For example, you can open it from the: Work List Patient screen Find Documents screen (search results) To open a quality indicator checklist or transition plan, in the Description column, click a quality indicator checklist description (for example, LOC: Acute Adult/Quality Indicator Checklist) or a transition plan description (for example, LOC: Acute Adult/Transition Plan). i Note: For more information, refer to Review Manager Help. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 111

112 Marking a Quality Indicator Checklist or Transition Plan "Complete" Marking a Quality Indicator Checklist or Transition Plan "Complete" As you work with a quality indicator checklist or transition plan, In Progress (in yellow) displays on the document tool bar. To mark the quality indicator checklist or transition plan "Complete," on the document tool bar, click Complete. Once the quality indicator checklist or transition plan is complete: 1. On the Quality Indicator Checklist screen toolbar, click Complete. 2. To record the checklist, click Save. The status changes from In Progress to Completed. The quality indicator checklist or transition plan becomes read-only; that is, it cannot be edited. The quality indicator checklist or transition plan no longer displays on your Work List. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 112

113 Chapter 4 Requests Managing Authorization This chapter introduces authorization requests and how to specify information for and then submit an authorization request in InterQual Review Manager. It also addresses managing the authorization results sent by a payer or other third party's authorization system. About Authorizations Requests While conducting a review, you can specify insurance, requestor, and other information and then submit an authorization request to a payer or other third party for authorization. When you submit the request, Review Manager first checks the member's eligibility against the payer's authorization system. If the member is eligible, Review Manager will continue to submit the request. The payer's authorization system then considers the review data and other authorization information and determines an authorization result. Review Manager receives and displays the authorization results such as authorization status and authorization number, if applicable. i Note: To enable member eligibility checking, your Review Manager system administrator must first configure the appropriate member eligibility settings in the Review Manager Administration Module. Additionally, your system administrator must enable authorization requests as well as add insurers, providers, and facilities. For more information, refer to the Review Manager System Administrator s Guide. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 113

114 About Authorizations Requests Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 114

115 Initiating an Authorization Request Initiating an Authorization Request Before you initiate an authorization request, you must do the following: On the Review Detail pane, select a Location. If you are conducting an InterQual Level of Care Criteria review that has review types, select a review type (for example, admission). i Note: You cannot submit authorization requests for discharge reviews. Additionally: On the Criteria pane, you might or might not have evaluated and selected criteria. On the Primary Outcome pane, you might or might not have selected a review outcome. If the review has an outcome, then that information is included with the request. The review must not have been previously submitted for authorization or, if it has been submitted for authorization, then the authorization status must be Denied, Rejected, Pended, or Canceled. If you submit a continued stay review for authorization, you can link it to a previous related admission authorization request. To initiate an authorization request, on the navigation pane, click Authorization. i Note: If you are conducting a Behavioral Health Criteria review, select the authorization request type: admission or service. If you are conducting a Level of Care Acute Adult or Pediatric Criteria review, select the review type: admission or continued stay. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 115

116 Initiating an Authorization Request The Authorization pane displays. The Authorization pane enables you to submit and manage authorization requests. Before submitting an authorization request, you enter information on the following tabs: Insurance Specify information about the subscriber and member. Requestor Specify information about the requesting provider and/or facility. Preadmission, Admission, Continued Stay, Service, or Referral Specify information about the requested item (for example, the admission or service) and the patient's diagnosis. i Note: The content of this tab is determined by the product you select and, in some cases, other factors. For example, if you select Level of Care Acute Adult Criteria and the admission review type, then the Admission tab displays. For more information, refer to "Entering Request-Specific Information" on page 119. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 116

117 Initiating an Authorization Request Entering Insurance Information The insurance tab enables you to specify information about the subscriber and the subscriber member. To enter information on the Insurance tab: 1. On the Review screen navigation pane, click Authorization. 2. Click the Insurance tab at the top of the Authorization pane. The Insurance tab displays. 3. Under Insurance Details, select a Subscriber ID/Policy. Insurance and Subscriber information displays. i Note: If necessary, you can edit the patient, add a subscriber, or add the member to an existing subscriber. For more information, refer to Review Manager Help. 4. Select a connection, if necessary. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 117

118 Initiating an Authorization Request i Note: Your Review Manager system administrator optionally sets up one or more authorization connections for each insurer in the Review Manager Administration Module. If more than one authorization connection is set up for the insurer, then you must select one. The authorization connection determines where the authorization request is submitted. i Note: Alliance Partners and Integrated Customers: Patient and insurance information is passed in by the integrated system or must be manually entered on an integration-specific version of the Insurance tab. For more information, refer to Review Manager Help. Entering Requestor Information The Requestor tab enables you to specify information about the requesting provider and/or facility. You must select a provider, a facility, or both. To enter information on the Requestor tab: 1. On the Review screen navigation pane, click Authorization. 2. Click the Requestor tab at the top of the Authorization pane. The Requestor tab displays. 3. Do one or both of the following: Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 118

119 Initiating an Authorization Request Under Requesting Provider information, select a Provider. Provider Information displays. Under Requesting Facility Information, select a Facility. Facility Information displays. i Note: If, on the Review Detail pane, you selected a Requesting Provider and/or a Facility with a National Provider Identifier (NPI), then the facility and/or provider is automatically selected on the Requestor tab. If you select a different provider or facility on this tab, then the information on the Review Detail pane is updated accordingly. Entering Request-Specific Information The Preadmission, Admission, Continued Stay, Service, or Referral tab enables you to specify information about the requested item (for example, the admission or service) and the patient's diagnosis. The content of this tab is determined by the product you select and other factors, as follows: Product Family Product Authorization Request Type Level of Care Acute Adult Admission or Continued Stay, based on the Acute Pediatric selected review type Behavioral Health Ambulatory Care Planning Retrospective Monitoring Long-Term Acute Care Rehabilitation Home Care Outpatient Rehabilitation & Chiropractic All products (except Procedures Q&A) Specialty Referral SIM plus Preadmission, Admission, or Continued Stay, based on the selected review type Service Service Admission or Service, based on the selected authorization request type Referral Service 1. On the Review screen navigation pane, click Authorization. The Authorization pane displays. 2. Click the [Request Type] tab at the top of the Authorization pane. Request types are Admission, Continued Stay, Preadmission, Referral, or Service. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 119

120 Initiating an Authorization Request The [Request Type] tab displays; for example, the Admission tab. i Note: If you are submitting a continued stay review for authorization, you can link it to a previous related admission authorization request by selecting the previous authorization from the Related Authorization drop-down list. 1. Complete request-type specific information. For example, Admit Date, Discharge Date (if the patient has been discharged), and requested number of days. The information requested varies according to the request type. 2. Select the Primary Diagnosis. If both ICD-9 codes and ICD-10 diagnosis codes are available, click the Primary Diagnosis drop-down to choose the type of diagnosis code, and then use the lookup to search for the code. i Note: A red asterisk indicates a required field. If, on the Review Detail pane, you entered information relevant to the request type (for example, Admit Date), then the same information automatically displays on this tab. If you enter different information on this tab, then the corresponding information on the Review Detail pane is updated accordingly. 3. Optionally, enter a comment. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 120

121 Submitting an Authorization Request i Note: For more information on entering request-specific information, refer to Review Manager Help. i Note: Alliance Partners and Integrated Customers: Service Provider/Facility and Referred to Provider/Facility are passed in by the integrated system or must be manually entered on integration-specific versions of the Service and Referral tabs. For more information, refer to Review Manager Help. Submitting an Authorization Request After you enter all of the required information on the Insurance, Requestor, and request-specific tabs, you can submit the authorization request. To submit an authorization request: on the Authorization pane (from any tab), click Submit Authorization Request. Review Manager displays a message indicating that the member's eligibility is being checked. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 121

122 Submitting an Authorization Request If the member is not eligible, Review Manager displays a message indicating that the member is not eligible and that the authorization request has been canceled. Click OK in the message. If the member is eligible, Review Manager continues to submit the request. If any required information is missing: A message displays, indicating the missing information. If the missing information message displays, click OK. Review Manager displays the left-most tab with missing information. Enter the required information. Click Submit Authorization Request again. A confirmation dialog box displays. It confirms the authorization connection you specified on the Insurance tab and explains that once the authorization request is submitted, you will not be able to edit information on the Review Detail, Criteria, or Authorization panes. Click Yes to submit the authorization request. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 122

123 Submitting an Authorization Request The Auth (Authorization) Results tab displays. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 123

124 Working with Authorization Results Working with Authorization Results After an authorization request is submitted, you can view and/or edit the authorization results (including the authorization status). About Authorization Status Authorization status tracks the communication and/or transaction status of an authorization request. The following describe the communication status: In Progress Review Manager is in the process of sending the authorization request to the authorization system. Submitted Review Manager sent the authorization request to and received an acknowledgement from the authorization system. Sent Review Manager send the authorization request, but did not receive an acknowledgement from the authorization system. There was no communication error. Server Unreachable Review Manager was unable to send the authorization request to the authorization system. There was a communication error. Manual No authorization request was submitted, because no authorization connection was set up for the selected insurer or no URI was specified for the selected authorization connection. The following describe the transaction status: Approved The authorization system processed and approved the authorization request. Denied The authorization system processed and denied the authorization request. Rejected The authorization system did not process the authorization request (for example, due to insufficient information). Pended The authorization system is processing the authorization request, but has not yet determined the result. Canceled A Review Manager user canceled the authorization request. Viewing Authorization Results You view authorization results on the Authorization pane's Auth Results tab. The current authorization results display at the top of the tab. Under History, historical authorization results display, starting with the most recent results. In the following example, the current results include an authorization status of Approved. Under History, the historical authorization results indicate that the Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 124

125 Working with Authorization Results authorization request was submitted, and then pended by the authorization system, and then approved. The authorization number is "a21321." You can also view the current authorization status from the Work List, the Patient screen, a care folder, and the Find Documents screen. In the Status column, the authorization status is appended to the review status or outcome. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 125

126 Working with Authorization Results Editing Authorization Results You edit authorization results on the Authorization pane's Auth Results tab. To edit authorization results: 1. On the Review screen navigation pane, click Authorization. 2. Click the Auth Results tab at the top of the Authorization pane. 3. To edit status information, click Edit Status. The Edit Status dialog box opens enabling you to make changes. 4. Select a Status (for example, Approved or Canceled). 5. If you select Approved, then enter the Authorization #, Expiration Date(s) and Approved Days, as appropriate. 6. Optionally, enter a Comment. 7. Click Save. A confirmation dialog box displays. 8. Click Yes. The authorization results are updated on the Auth Results tab (and elsewhere), as appropriate. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 126

127 Chapter 5 Exporting Reviews This chapter introduces exporting reviews from InterQual Review Manager to another Review Manager system (or other application). It also addresses working with imported (that is, foreign) reviews. About Exporting Reviews You can export a review (or other document, such as a quality indicator checklist or transition plan) to another Review Manager system (or other application). That system, in turn, imports the review, where it is referred to as a "foreign review." A foreign review is a snapshot of a review from another Review Manager system (or other application); it cannot be edited. Foreign reviews can also be exported. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 127

128 Exporting a Review Exporting a Review To export a review: 1. On the Review screen navigation pane, click Export. The Export pane displays. 2. Select a Destination. i Note: Your Review Manager system administrator must set up one or more destinations (that is, export connections) in the Review Manager Administration Module. The destination determines where the review is exported. 3. Optionally, enter an Export Comment. 4. Optionally, select the comments (for example, Reviewer Comments) to include in the exported review. 5. Click Export. A confirmation dialog box displays. 6. Click Yes to export the review. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 128

129 Working with Foreign Reviews The Export History displays. Working with Foreign Reviews After a review is exported to another Review Manager system and then imported into that system as a foreign review, it displays on the Work List of the appropriate reviewer. i Note: The Review Manager system administrator must enable importing reviews (and other documents) and specify a user to whom imported reviews are initially assigned in the Review Manager Administration Module. A review number with the prefix "F" or a description with the prefix "Foreign" indicates a foreign review. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 129

130 Working with Foreign Reviews Assigning a Foreign Review to Another Reviewer To assign a foreign review to another reviewer: 1. On the Work List, in the Assigned To column, click the reviewer's name. The Assign Reviewer dialog box displays. 2. Select a reviewer from the list. 3. Click Save. i Note: The review now displays on the Work List of the selected reviewer. Change Healthcare LLC and/or one of its subsidiaries. All rights reserved. 130