Pre-screen allows you to validate Member, Dates of Service nd Provider Signatures before a document goes to data entry. This workflow can be configured in Project Settings for any Risk or IVA project.
Benefits
By utilizing this workflow, health plans can see the following benefits:
- Reduce coding efforts by validating the completeness of medical records upstream
- Retrieve missing medical record information prior to data entry
- Perform a collection only workflow that also verifies record completeness
Who Can Use It?
Manager and above, or Employees with Document QA privileges.
How it Works
- If a project is configured to verify both member and dates of service in a document, you will be required to perform a more thorough review of medical record.
- First, you will verify if the member is correct
- Then, you will verify that each admin date of service is present in the record
- If the date of service is present, you will also be tasked to verify that there is a provider signature present.
- Once you submit, an additional chase called a pursuit may be generated based on results of the review.
- If a pursuit is created for a chase, the original chase will be referred to as the parent chase.
- See below for an example of a document review screen for a project configured to review Member and DOS validation:
Configure ‘Document Review Level’ for your Project
For Risk or IVA project, the ‘Document Review Level’ can be configured to either ‘Member Validation’ or ‘Member and DOS Validation’. This setting is a dropdown located on the ‘RISK Settings’ and ‘IVA Settings’ tabs within your Project Settings
Project configured for member validation:
Project configured for member and dates of service validation:
Reviewing a Medical Record in Document Review
If Member Validation configured
Member Validation – Is Valid
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Member Validation – Is Not Valid
Chase moves back to chart collection to be requested and retrieved again |
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If Member and DOS Validation configured
Member is Not Valid
Chase moves back to chart collection to be requested and retrieved again |
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Member, DOS, and All Provider Signatures are Valid/Present on Parent Chase
Chase moves to next status (either Data Entry or Completed) |
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Member, DOS, and All Provider Signatures are Valid/Present on Pursuit Chase
Pages are copied from pursuit to parent chase, parent chase PC700 gets resolved, and Pursuit is pended and closed with PC700 |
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Member is Valid but Missing a DOS
A 'Pre-Screen' pursuit is created which contains all missing DOS, Parent Chase is pended PC700 |
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Member is Valid, all DOS Present but Missing Signature
A 'Pre-Screen' pursuit is created which contains all missing provider signatures, Parent Chase is pended PC700 |
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Member is Valid, DOS and Signature are Missing
A 'Pre-Screen' pursuit is created which contains all missing DOS and provider signatures, Parent Chase is pended PC700 |
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Identification
Regardless of how a project is configured for Document Review, users will still be able to edit the pages that are attached to a chase under the ‘Identification’ tab. While member and dates of service validation are available on the ‘Review’ tab, users can simply navigate to the ‘Identification’ tab to remove pages, change the chase ID or identify an invoice.
After submitting the chase document, the following actions will occur based on the results entered:
Scenario | Outcome |
Any Chase
Correct Member = No
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Parent Chase
Correct Member = Yes DOS = All Yes Provider Signature = All Yes
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Parent Chase
Correct Member = Yes DOS = One or more No
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Parent Chase
Correct Member = Yes DOS = All Yes Provider Signature = One or more No
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Parent Chase
Correct Member = Yes DOS = One or more No Provider Signature = One or more No
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Pursuit Chase
Correct Member = Yes DOS = All Yes Provider Signature = All Yes
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Managing the Document Review process for Your Project
If a user is set up as an Admin, Retrieval Lead or Retrieval Manager they will be able to see and manage the document review progress for their projects in the following places:
Document QA
By navigating to Retrieval > Document QA page users can see all chases that are currently in document review:
- This list will contain chases that fall into two categories:
- Chases that are pended
- Chases that need to be reviewed
- These can be differentiated by using the ‘Status’ column:
- If a chase has a status of ‘Doc Review,’ then it still needs to be reviewed
- If a chase has a status of ‘Pended,’ then it is currently pended
- If a chase is pended users can:
- Click the chase ID and see the results previously completed
- If it is desired that a pended chase is moved forward in the process before the pursuit is retrieved, users can select the chase(s) on the table and then click ‘Pend Chases’.
- From here you can change the status to ‘resolved’, which allows the chase to proceed without the pursuit.
Retrieval Pends
All chases and pursuits that have been pended PC700 based on document review can accessed from retrieval pends by navigating to Retrieval > Retrieval Pends.
- The table can be filtered down to show only PC700, regardless of chase or pend status
- From here you can see the state of that chase
- If it is still waiting to be retrieved
- If we have received the pursuit already
- Resolved manually
- Pends can also be resolved from this page by selecting the pend in the grid and clicking ‘Change Status’.
Approval Center
Pursuits that are created during the prescreen process will be subject to the approval center settings.
- If your project is configured to require pursuit creation approval, then the pursuit will need to be approved in the approval center
- If the project is not configured to require approval for pursuits, then any pursuit generated by prescreen chase submission will be automatically created and appear at the address of the original chase for retrieval.
Moving Chases with Bulk Actions
If it is desired to move one or more pended chases further down the workflow, this can be done manually using bulk actions. Users can export a list of the desired chases or pends from one of the filtered tables in the platform and use it to perform bulk actions. The following two actions must occur to move pended chases:
- Resolve Pends: this can be done either by selecting chases / pends in the ‘Document QA’ or ‘Retrieval Pends’ grids and resolving pends as described in previous sections. This can also be done using the bulk action found under Bulk actions > Change > Pends > Resolve
- Move Chases: moving chases to the desired status beyond document QA can be done using the bulk action found under Bulk Actions > Change > Chases > Move Chases. From here, users can select the desired status and enter the chases in either a comma separated list or by uploading a csv
Analytics
In addition to viewing progress in the Document QA and Retrieval Pends pages, users can find a variety of reports and dashboards under the Analytics section of the application. See below for some of the reports that can be used to monitor and analyze progress relating to Document Review for your project:
- Pends Summary: This dashboard gives a high-level summary of all pend activity for the selected projects. This can be used to review the total number of chases that have been pended for pursuits relating to document review
- Chase Status Underlying: This extract gives a detailed view of every chase for the selected projects. This data can be used to analyze a wide variety of things for your project, including total chases pended, current chases pended, total pursuits created, and total pursuits received.
- Prescreen report Designed specifically for the pre-screening of records. This report can be used to determine any outstanding DOS and/or Provider Signatures for the chases that have been reviewed.
- Additionally, it can be used to review volume of pursuits, pends, and outstanding chases.