Alert Code Basics with Roles

Case Manager Update is Overdue

Fires when a patient's update has not been marked as "sent" on the Update Log tile

Grandpa Joe's update is due on 8/1/23.  Today is 8/2/23 and the update is showing as "not sent".

Check to make sure the update was sent to the payer and mark as "sent" in the Update Log tile.

CM

Check If Stay Diagnosis Appears In Not Assigned Group

Fires when a patient's diagnosis does not match the Authorization "diagnosis" level assigned

Grandma Alice is a bariatric patient, but her assigned level for the UHC Authorization is "skilled" instead of "bariatric".

Change her level of care to bariatric.

CM/Clinical

Check Insurance Coverage Dates For Gaps

Fires when there is a gap in insurance coverage for a patient.

Grandma Alice shows one IVF coverage for 1/05/23-1/20/23 and another IVF coverage for 1/22/23-1/30/23.  January 21 is not covered.

Adjust the coverage date to include 1/21.

CM/Clinical/BOM

Check Assigned Level of Care for Provided Therapy Date

Fires when a patient receives therapy and there is no level of care assigned.

Grandma Alice receives 35 minutes of PT, but her Authorization is missing a level of care.

Enter the level of care.

CM

Pharmacy to bill medications directly to Payer.

Grandma Alice - Pharmacy to bill medications directly to payer BCBS of LA, Insurance ID 105679157599, coverage start date 01/10/2023.

Grandma Alice’s payer is BCBS LA, this payer requires the pharmacy to bill all medications directly to them instead of the SNF to bill them.

Inform BOM not to bill medications to the Payer as the pharmacy will bill them directly.

CM/BOM

Order Received is an Exclusion

Fires when a patient receives an order that is excluded on the contract.

Grandma Alice receives Lovenox, but this medication is listed as an exclusion.

Obtain an authorization from the payer or see if there is an alternative medicine.

CM/Clinical/BOM

Check Ordered Item Count Day Limit

Fires when a patient receives more than the allowed amount of a service for the assigned level of care.

A contract states that patients at level 1 are not allowed to receive more than one third generation antibiotic per day.  Grandpa Joe received two.

Obtain an authorization from the payer or see if there is an alternative medicine.

CM/Clinical/BOM

Check Order Item Count Week Limit.

Fires when a patient receives more than the allowed amount of a service for the assigned level of care.

A contract states that patients at level 1 are not allowed to receive more than one third generation antibiotic per week. Grandpa Joe received two.

Obtain an authorization from the payer or see if there is an alternative medicine.

CM/Clinical/BOM

Ordered Item is Excluded for Level

Fires when a patient receives an order that is excluded for their assigned level of care.

Grandma Alices is assigned to level 1 and receives TPN.  TPN is not an allowable service for level 1.

Obtain an authorization from the payer or see if there is an alternative.

CM/Clinical/BOM

Check Ordered Items For Cost Limit

Fires when all medications cost exceeds the contracted dollar amount for the assigned level of care.

A contract states that medications totaling over $200 per day may be separately reimbursed.  Grandpa Joe's medications total $220 per day.

Obtain an authorization from the payer.

CM/Clinical/BOM

Check Ordered Items For Level Sum Cost Limit - Parameter

Fires when a patient's medications cost exceed the contracted dollar amount for a set parameter and assigned level of care.

The contract states that any 3 medications that a patient receives cannot exceed $240 per day at level 1.  Grandma Alice receives Abilify, Epogen, and Glucagon and these medications total $270.

Obtain an authorization from the payer.

CM/Clinical/BOM

Check Ordered Item For Level Item Cost Limit

Fires when one medication cost exceeds the contracted dollar amount for the assigned level of care.

The contract states that any one medication that a patient receives cannot exceed $75 per day at level 1.  Grandma Alice receives Glucagon and this medication cost is $140.

Obtain an authorization from the payer.

CM/Clinical/BOM

Check All Ordered Items For PDPM Item Cost Limit

Fires when one medication cost exceeds the contracted dollar amount for the assigned HIPPS code.

A contract states that any one medication that a patient receives cannot exceed $100 per day for any assigned HIPPS.  Grandpa Joe receives Glucagon and this medication cost is $140.

Obtain an authorization from the payer.

CM/Clinical/BOM

Check Ordered Service as High Cost Medication or Carve Out

Fires when a service/medication is ordered that is flagged as a high cost medication, carve out, pharmacy exclusion, etc. (The alert message is customizable)

Grandma Alice receives Glucagon and this medication is flagged as a high cost med.

Obtain an authorization from the payer or see if there is an alternative medicine.

CM/Clinical/BOM

High Priced Ordered Service

Fires when a medication cost exceeds a certain amount defined by leadership.

Leadership has determined that any medication over $250 should receive an alert.  Grandma Alice receives Glacagon  and it is $252.

See if a carve out can be obtained from the payer or if there is an alternative medication available.

CM/Clinical/BOM

Single Discipline Therapy Provided Exceeds Daily Limit

Fires when a patient's therapy minutes for any one discipline (PT or ST or OT) goes over the contract limit for the day.

A contract states that a patient at level 1 may receive 30 - 60 minutes of therapy per day.  Grandma Alice is assigned to level 1 and she receives 65 minutes of PT for the day.  65 > 60

Communicate with therapy team to see if a higher level of care should be requested from the payer, or formulate a plan to reduce provided minutes.

CM/Therapy

Single Discipline Therapy Provided Exceeds Weekly Limit

Fires when a patient's therapy minutes for any one discipline (PT or ST or OT) goes over the contract limit for the week.

A contract states that a patient at level 1 may receive 210 - 420 minutes of therapy per week.  Grandma Alice is assigned to level 1 and she receives 475 minutes of PT for the week. 475 > 420

Communicate with therapy team to see if a higher level of care should be requested from the payer, or formulate a plan to reduce provided minutes.

CM/Therapy

Multi Discipline Therapy Provided Exceeds Daily Limit

Fires when a patient's therapy minutes for any combination of disciplines (PT and ST and OT) goes over the contract limit for the day.

A contract states that a patient at level 1 may receive 30 - 60 minutes of therapy per day.  Grandma Alice is assigned to level 1 and she receives 30 minutes of PT, 15 minutes of OT, and 20 minutes of ST for the day. 30+15+20 = 65   65 > 60

Communicate with therapy team to see if a higher level of care should be requested from the payer, or formulate a plan to reduce provided minutes.

CM/Therapy

Multi Discipline Therapy Provided Exceeds Weekly Limit

Fires when a patient's therapy minutes for any combination of disciplines (PT and ST and OT) goes over the contract limit for the week.

A contract states that a patient at level 1 may receive 210 - 420 minutes of therapy per week.  Grandma Alice is assigned to level 1 and she receives 200 minutes of PT, 150 minutes of OT, and 100 minutes of ST for the day.  200+150+100 = 450   450 > 420

Communicate with therapy team to see if a higher level of care should be requested from the payer, or formulate a plan to reduce provided minutes.

CM/Therapy

Multi Discipline Therapy Provided Below Daily Limit

Fires when a patient's therapy minutes for any combination of disciplines (PT and ST and OT) is under the contract limit for the day.

A contract states that a patient at level 1 may receive 30 - 60 minutes of therapy per day.  Grandma Alice is assigned to level 1 and she receives 10 minutes of PT, 10 minutes of OT, and 5 minutes of ST for the day. 10+10+5 = 25   25 < 30

Communicate with therapy team and formulate a plan to ensure patient is receiving the required therapy minutes.

CM/Therapy

Multi Discipline Therapy Provided Below Weekly Limit

Fires when a patient's therapy minutes for any combination of disciplines (PT and ST and OT) is under the contract limit for the week.

A contract states that a patient at level 1 may receive 210 - 420 minutes of therapy per week.  Grandma Alice is assigned to level 1 and she receives 100 minutes of PT, 50 minutes of OT, and 50 minutes of ST for the day.  100+50+50 = 200  200 < 210

Communicate with therapy team and formulate a plan to ensure patient is receiving the required therapy minutes.

CM/Therapy

Provided Service is an Exclusion for the Level of Care

Fires when a patient receives therapy and therapy is not an allowable service for their assigned level of care.

A contract states that therapy is not allowed at level 1.  Grandpa Joe receives 60 minutes of therapy. 60 > 0

Inform therapy team that therapy is not allowed.  Communicate with payer to obtain therapy authorization or higher level of care that includes therapy.

CM/Therapy

Multi Discipline Therapy Provided Below Weekly Days Limit

Fires when a patient does not receive the required number of days of therapy for their assigned level of care.

A contract states that a patient must receive at least 5 days of therapy.  Grandma Alice only receives 4 days of therapy.  4 < 5

Communicate with therapy team and formulate a plan to ensure patient is receiving the required days of therapy.

CM/Therapy

Multi Discipline Therapy Provided Exceeds Weekly Days Limit

Fires when a patient receives more than the required number of days of therapy for their assigned level of care.

A contract states that a patient is only allowed to receive therapy 3 days a week.  Grandpa Joe receives 5 days of therapy.  5 > 3

Communicate with therapy team and formulate a plan to ensure patient is receiving the required days of therapy.

CM/Therapy

Therapy Gap to Next Level of Care (Multi-discipline)

Fires when a patient is a defined number of minutes away from the next level of care.

Grandpa Joe (level 1) has received 83 minutes of PT/OT/ST.  The payer's next level of care (level 2) starts at 90 minutes of therapy.  The alert will fire and say that Grandpa Joe is 7 minutes away from the next level of care.

Communicate with therapy team to see if they are able to provide a few more minutes to try and gain a higher level of care.

CM/Therapy

Patient Admission Authorization is Expired

Fires when a patient is missing an authorization or the authorization is not valid.

Today's date is 1/25/23 and Grandpa Joe has no authorization entered.  Grandma Alice has an authorization entered, but it is only valid from 1/01/23-1/15/23.

Obtain valid authorization from the payer.

CM/BOM

Patient Admission Authorization will Expire in One Day

Fires when a patient's authorization will expire in one day.

Grandpa Joe's current authorization will expire on 1/30/23.  Today's date is 1/29/23, so alert will fire.  

Obtain valid authorization from the payer.

CM/BOM

Discrepancy in Resident HIPPS Information

Grandma Alice – HIPPS code entered does not match the MDS HIPPS code pulled from the EHR.

Grandma Alice - HIPPS code KAPD entered in the authorization 4994268 start date 06/25/2024 does not match the MDS HIPPS code IAMD1 effective date 06/28/2024 pulled from the EHR.

Varies, Depends on Payer on accepting MDS results.

CM/Clinical/BOM

Check Level of Care has Changed

Fires when a patient's level of care has changed.

A user updated an authorization in MCM increased Grandpa Joe's level of care from level 1 to level 2.  

Inform therapy team to ensure they are providing the required amount of therapy for the new level of care.

CM/Therapy/BOM

Follow Up Is Past Due By a Specific Number of Days

Fires when a patient has a past due follow up scheduled on the calendar and is not marked as completed.

Today's date is 3/15/23.  Grandpa Joe has a follow up scheduled for 3/13/23.  The follow up past due flag is set to 2 days.  

Review the follow up log for any actions needed and mark as complete.

All

Carve Out Approved.

Grandma Alice - Approved for AMRIX ER 15 MG CAPSULE on 02/28/2024 for Authorization Number A164081101.

Grandma Alice’s payer is BCBS LA, this payer approved the carve out for the resident.

Inform BOM not to bill medications to the Payer as the pharmacy will bill them directly.

CM/Clinical/BOM

Exclusion Approved.

Grandma Alice - Approved for AMRIX ER 15 MG CAPSULE on 02/29/2024 for Authorization Number 1594567TT.

Grandma Alice’s payer is BCBS LA, this payer approved the exclusion for the resident.

Inform BOM not to bill medications to the Payer as the pharmacy will bill them directly.

CM/Clinical/BOM