Medical Review

AgileEMR: Medical Review 

FEATURE PURPOSE: The Medical Review feature allows users to track when an insurance mandates that medical documentation/paperwork needs to be sent into an Insurance after a number of days, visits or units billed for a case. This feature includes case prompts, schedule alerts, and work queue items when a medical review is due soon or due now. 

Turn on Medical Review:

  • Navigate to the Insurance Tab
  • View Insurance that you wish to turn on the feature

  • Click the checkbox for Medical Review Feature
  • System will display three fields to track when the Medical Review is due:
    • Days
    • Visits
    • Units Billed

  • Enter in the fields for tracking that are applicable for this patient and update the Insurance Coverage

Mandatory Medical Review based on Insurance:

  • Administrators in your company have the option to mandate that a Medical Review information must be filled out based on an Insurance Plan
  • When you select an Insurance plan that requires Medical Review the system will automatically display the Medical Review fields
  • Enter in the fields for tracking that are applicable for this patient and update the Insurance Coverage

How the System Alerts for Medical Review:

Insurance Tab Status Bar

  • Under the Insurance Tab for plans Marked for Medical Review you will find the following Statuses:

  • Good Standing means that the Medical Review information has been entered and there are no actions needed at this time.

  • Required means that a Medical Review is now due after one of the entered fields of days, visits or unit billed has ran out from the countdown.

  • Due Soon means that a Medical Review is due within 7 days, 3 visits or 10 units billed.

  • Pending means that a Medical Review has been sent to the Insurance Company and is now pending review.

  • In Appeal means that a Medical Review originally was denied by the Insurance Company but an appeal has been sent to attempt to get more treatments approved.

  • Approved means that a Medical Review was sent and approved for additional treatments by the Insurance Company. 

  • Denied means that a Medical Review was sent and ultimately denied for additional treatments. 

Case Home Page Insurance Information

  • The Medical Review statuses and count down information will also be visible on the Case Home Page under the Insurance Section. Please see an example below:

Schedule Alerts

  • When you go to check in a patient and a Medical Review is due soon, the Medical Review Status will be orange within the Appointment Popup box. Additionally, the patient’s name will display in orange.

  • Click the Question mark to the left of Medical Review Status to bring up the Medical Review Status table in the appointment pop up. 

  • When you go to check in a patient and a Medical Review is due, the Medical Review Status will be red within the Appointment Popup box and the patient name will display in red.

  • Click the Question mark to the left of Medical Review Status to bring up the Medical Review Status table in the appointment pop up.

  • When you arrive the patient where the Medical Review is due, the following popup will display as reminder that action is necessary for the patient.

  • When you go to check in a patient and a Medical Review has been sent and is pending, the following alert within the Appointment Popup box and the patient name will display in orange.

  • If you arrive the pending appointment a popup will occur as a warning a Medical Review is pending for that Insurance Plan.

  • When you go to check in a patient and a Medical Review has been sent and marked as denied, the following alert within the Appointment Popup box and the patient name will display in red.

  • If you arrive the denied appointment a popup will occur as a warning that services have been denied by the Insurance company.  Please see below:

Work Queue Tasks

  • Medical Review tracking for an Insurance Plan will provide the following tasks for the users within the Work Queue:
  • When a Medical Review is due soon or due a Review Sent task will display, providing a way to track that the paperwork has been sent to the insurance company.

  • Once a Medical Review has been sent the task will change the action buttons to Approved or Denied for a user to mark when they receive feedback from the Insurance Company on their decision.

  • IF a user clicks approved the review task will disappear and the Approved status will display in the Insurance Tab, Daily Notes and Case Home page for the case.
  • IF a user clicks denied a popup will occur asking if the status should be marked as denied (final denial) OR as in appeal.

  • IF the user marks In Appeal the task will revert to Approved or Denied until the decision on the appeal is marked for the case. 
  • IF the user marks the status as Denied then the review task will disappear and the Denied status will display in the Insurance Tab, Daily Notes and Case Home page for the case.

NOTE: If there was ever a mistake in how the status for the Medical Review was marked, this may be reversed by going to the Archive Work Queue and performing an Undo on the status.

Daily Note Header Alerts

  • Therapist will also be able to see the state of the Medical Review through a Medical Review Status table listed in the Daily Note Headers.  Please see an example of this below: 

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