STD Claim Analysis

RESOURCE UPDATE: Client continues to report last week she went to Center 37 and she was told that her Center is now 066. Client was upset that she was transfer to another shelter. As per the client she will lose her Linc V if she is transferred to Center 66. CM tries to explain to the client HRA transfer many clients because Center 37 is overcrowded. Client reported she requested for her case to be closed. Client continues to report she spoke with HRA Rep Ms. Perez who requested for the client to put her request in writing. Client stated she did put her request in writing to have her case closed from center 66. Then the client provided this worker with copy

SC received a telephone call on 10/16/2015 stared 9:34 and end at 9:41 am from Tricia Crooks at Liberty Resources Home Choices (LRHC) Community Outreach and Enrollment Leader. Stating that she spoke Pa and he wants to resume his service order with LRHC for PAS service. SC informed SC that this information will first need to verify with Pa. SC expressed concerns about LRHC being able to fulfill service since they had the case unstaffed for over two weeks (09/25/15-10/15/2015). Tricia apologized on behalf of LRHC, and stated that they have someone assigned and is ready to go all is needed is the resumed service order ASAP. SC again explained to Tricia that Pa has to confirm this besides Pa was very adamant about switching provider because the

Housing Update: client NY NY I, II was approved. Client is waiting for DHS manifest to tour apartment. Another alternative housing is MRT once client SSI is approved. Client also mentioned she signed up with Brightpoint Health Home Health Services since 5/9/2015, Client report she will like to sign up with CAMBA/Home Health and she provided BrightPoint Home Health approval letter for CM to submit to CAMBA/Home Health Coordinator. Client is waiting for her coordinator at Brightpoint to return from vacation to close her case, so that she can sign up with CAMBA/Home Health

Frankie Tilmon continues to be out of treatment compliance. Frankie has missed his last four appointments, 7/2/15, 7/9/15, 7/16/15, and 7/30/15. Frankie contacted this provider on 7/6 to apologize for missing his appointment on 7/2 and was reminded of his next appointment on 7/9, which he agreed to attend. On 7/15 Frankie contacted this provider to apologize for missing his treatment appointment on 7/9 and agreed to make his appointment the following day, which he failed to appear for. On 7/16 Frankie contacted this provider to again apologize for missing his appointment and wanted to confirm his next scheduled appointment day/time. I told Frankie that his appointment day and time has not changed; it was on Thursdays at 4pm. Frankie told

The medical form was not totally in compliance with the “Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), even though the claimant had a written notice there was no effort put forth in order to secure an approved medical authorization and

On 03/11/2016 SC met with Pa in her apartment for a RA visit. Pa 's Agency Model PAS aide was not present while SC was there. The Pa appeared poorly groomed and dressed in dark color clothes. The apartment was dirty and cat litter and feces on the table and floor. All utilities are in working order. The Pa reported numerous hospitalizations between Temple University and Episcopal University. The Pa did know the exact dates of admission and/or discharge. However, the Pa stated that reasons for admission were either asthma exacerbation; COPD and/or fluid around the Lungs. The SC placed call to Temple University Hospital medical records department and inquiries about Pa admission and discharges. The SC was placed on hold for a long time and when the SC did speak with the receptionist she stated that most of the Pa admission was at Episcopal Hospital Temple University and she did not have the time to go over every admission she provided the SC with the medical records department telephone number for Episcopal. The SC thanks her for her time and end call. The dates of ER visits and hospital admissions are as follows: 11/2015, 12/2015, 3/1/2016-3/4/2016, 3/5/2016-3/6/2016; and two ER visits 2/29/2016 and 3/7/2016 at Temple University. SC reviewed Pa’s services and per Pa he is receiving services in the type, scope, amount, frequency and duration as specified in the ISP. But the SC reasons to doubt that the Pa is receiving service according to the ISP. The SC arrived at the Pa’s

Cassie (Program Manager, Employee Health) emailed Don Foster FML Denial letter informing Officer Foster his request for FMLA was not approved. Ms. Miles informed Officer Forster their was no enough information contained in the application for it to be approved. He was offer the option to request non-FML leave of absence. Officer Foster never attempted to call or contact Ms. Miles to provide a response. The FML letter was emailed to Officer Foster's immediate supervisor, who attempted to contact him to ensure he received the FML and leave of absence letter. Officer Foster did not answer nor did he return SSM Kaylor's phone

CM was out on vacation for the period of 11/25/2016 to 12/12/2016. Client was scheduled to meet with CM on 12/13/2016, to complete Bi-Weekly ILP Review. Client was no show. CM inquire the reason client was no show. Client replies “she wasn’t feeling well and she went to LIJ Emergency Room. On 12/15/2016, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed with proper attire for the weather. She was well-mannered and groomed. In the meeting client appears to be cooperative

Case manager met with client to develop and issue an independent living plan, which indicated client must apply for public assistance benefits within three business days. Client agreed to apply for full public assistance benefits. Client received and signed and appointment notice, which indicated, the appointment date, time, location, and travel directions. A metrocard was provided to client to attend this appointment. Client was notified that he/she must provide proof of applying by 19/13 Client understood and agreed to apply for PA on 1/2/13 and provide proof on 1/2/13 the client was also notified to comply with all follow up HRA appointments to maintain an active public

Would you please contact patient and verify 2ndry Ins. information . I just receive a denial from her 2ndry insurance that we have on system saying that the patient is coverage under another payer. We receive payment already from Medicare and I bill out on paper and attach the Medicare EOB to the claim to her 2ndry insurance on 3.1.2017 and now the payer denied the claim. I transfer the visits to self paid but if the patient provide to us her 2ndry Insurance information we can bill the claim back to the payer. Please advise.

“The specific reason for this denial of your appeal for Harvoni is that the coverage guidelines had not been met

Client came into social service after receiving a SUS appointment slip left at the front desk by CM 10/3/17 to meet on 10/5/17 at 4pm. Client stated she only had a few minutes to talk because she had to cook dinner. Client informed CM her PA account was closed and she replied once again. Client also reports she has to visit Connecticut, PA office for a letter stating her PA case is closed in that state. Client informed her CM all documents requested will be submitted within a weeks’ time. Client reports two of her four daughters Selah McKenzie and Olivia Lue have a doctor appointment tomorrow October, 5, 2017. The other two daughters, Trinity and Nyan McKenzie have appointments next week Tuesday on October 10,

Client and this CM was able to complete all three forms. Client stated to this CM working on Friday at 12PM to Monday at 12PM each week as home health aide in New Canaan for an 89-year-old women. Client expressed happiness to be employed. Client stated being homeless since June of 2016 when due to getting kicked out of father's household. Client stated needing help to get housed is the reason for requesting case management services. Client stated to this CM being kicked out of father's house was due to drug usages. Client is currently receiving $383 monthly from SNAP and make roughly $1890 monthly from job. Client stated to this CM utilizing the Day Street Clinic in Norwalk CT as a primary care provider. Client also stated to this CM receiving therapy from Rebecca at Day Street Clinic for pass history of trauma. Client stated to this CM being raped three years ago and have a history of sexual abuse. Client stated to this CM medical history contains heart murmur. Client currently is taking 500mg of trazadone nightly. Client is diagnosed with depression and bipolar disorder. Client stated to this CM having 8 children, 6 biological and 2 adopted. Client family history contains depression and high blood pressure. Client scored 8 on the CAGE Assessment and scored 15 on the Modified

PA/Entitlements/ Benefits: Client has an active PA case. Client had a SSI appointment on 6/2/2015. Pending response

Just an FYI, escalation#1580 is not a true escalation. Claim#124210654800 had an appeal sent back on 05/05/2015 appeal# APP-1186293. I understand that the appeal was dismissed because of the rep. didn’t note the document ID#. But we must understand that this is the first level of appeal. Once the appeal has been closed out, the provider must send in a 2nd level appeal. I’m not sure, if you advise the provider that the submission of your escalation doesn’t halt the timely filling of the 2nd Level. Which has now passed. Going forward, please be sure to review the appeal to determine if it is a true escalation or not. This can be based on discrepancies in the discussion based off the reason why the appeal was sent back. For this escalation, I