Medical Necessity Determination Process

1
Medical Necessity Determination Process

• Assessments are reviewed by TMHP nurses within 3
  business days of receipt.
• Assessments may remain in pending denial up to 21
  calendar days. During this time additional
  pertinent medical information may be submitted
  for review.
• If an assessment is placed in a denied status,
  additional information must be received within 14
  calendar days of the date of denial letter.

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2
Portal FSI
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3
Corrections

• If incorrect data on the MN and LOC Assessment is
  submitted or RUG of BC1 has been assigned, the
  provider can submit a correction.
• Examples of incorrect data are
• Individual listed as a male but is actually a
  female.
• Individuals diagnosis notes diabetes but the
  individual actually has hypoglycemia.
• Corrections are not allowed to all assessment
  fields (i.e., individual demographic information
  and assessment date).
• Providers must access the assessment utilizing
  Form Status Inquiry (FSI) or Current Activity.
• Corrections must be completed on the LTC Portal
  within 14 days of original submission.
• TMHP will place the original assessment into a
  corrected status and give the new assessment a
  DLN creating a Parent/Child DLN relationship.

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4
Inactivations

• MN and LOC Assessments can be inactivated from
  the system.
• An example of an inactivation is when fields
  cannot be corrected. (i.e. Medicaid and
  individual name)
• Inactivations must be performed through the LTC
  Online Portal by a search through FSI or Current
  Activity.
• There are no time limitations to perform an
  inactivation.
• Assessment will be placed in a status of
  Inactivated.
• Once the assessment is inactivated it cannot be
  reactivated, and a new assessment must be
  submitted.

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5
Status and Messages

• Providers can retrieve the status of their MN and
  LOC Assessment by accessing FSI or Current
  Activity on the LTC Online Portal.
• Medical Necessity (MN) Approved - Assessment has
  been reviewed and approved by TMHP. No further
  action by provider is required.
• Pending Medicaid ID - The system is verifying the
  Medicaid ID. No further action by provider is
  required.
  
  

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6
Status and Messages (cont.)

• ID Confirmed- Individuals Medicaid ID has been
  confirmed for the dates of service submitted.
  Provider must submit/update all required
  assessments and forms.

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