Considerations for Using UM
Medecision’s Utilization Management solution is designed with compliance and accuracy for auditing in mind. When a new request is saved, it becomes a snapshot of all the data recorded as part of the Intake process, along with relevant member and provider information.
How this Impacts You
Any changes to the data in the snapshot is not reflected in any existing requests, regardless of a request’s status. This also applies to reports.
Data in the Snapshot
Member Demographics: Name, date of birth, gender, client code, state, and ZIP Code.
Member Identifiers: Medecision ID and alternate IDs
Member Enrollment: Subscriber ID, PCP, effective and termination dates, line of business code and description, group ID and description, plan Code and description
For providers with an active role on the request:
Provider Demographics: Name, address, email, phone numbers
Provider Identifiers: Medecision ID and alternate IDs
Possible Examples
A referral was approved for Jane Smith for a month of physical therapy. Jane called to have her surname updated to Maestro since she got married last week. In a monthly report of referrals, Jane Smith is listed on the request but in the user interface, Jane Maestro is displayed.
You are doing intake on an outpatient request for a consult. You notice the provider’s Tax ID is not in the provider profile. You do not have access to the system where the Tax IDs are stored. The task you create to hand off to your supervisor includes a note to add the Tax ID. Your supervisor adds this data, but the request does not contain it. It will also not be included in any reports.