CSBD Review Tools

What does LOC stand for?

• Level of Care

• Length of Care

• Line of Credit

• Log of Clinicals

Customized MCG versions include

• Guidelines that are customary for the member's region

• Guidelines tailored for our customers (members)

• Elevance Customized Guidelines

• Experimental and Investigational Guidelines

T of F: Medical Policies are developed for services that may be considered Experimental or Investigational.

• True

• False

Which of the following are Carelon services/guidelines?

• Musculoskeletal

• Sleep Studies

• Genetic Testing

• High Dollar Radiology

• SNF Or Rehab Facility

When reviewing CGs in OMPTA, you will likely have to check _______.

• All of the definitions at the bottom of the page

• The Customized Versions

• The Timeframe per State Addendum

• Clinical UM Guidelines Adopted By Plan

T or F: If there is a Medical Policy that comes up in your search in OMPTA, you will always use it

• True

• False

• If it makes sense depending on the member's clinical situation

T or F: Next week, I will learn how to apply the criteria to a case and document my review in ACMP

• True

• False

Why would you pend a case to the Medical Director/PCR? Select all that apply.

• I'm in a bad mood

• Medical Necessity is not met

• There is a limitation to this member's benefit

• As a nurse, I do not have authority to approve on my own

• The inpatient case does not meet for additional days in the hospital

What would you do if MCG shows a service can be done Ambulatory?

• Pend to the PCR

• Nothing, just document it

• Make a good clinical note and approve the case

• Switch from an ISC to a GRG

True or False: The criteria I am reading in OMPTA, Carelon or MCG may have clarifying information in the Appendix or Table of Contents (MCG).

• True

• False