Routing Rules

This document explains the purpose and functionality of the Routing Rules module. This module is utilized to automate incoming SARs submitted by providers to be routed to a specific MCO staff member. Explanations on how to create, modify and remove routing rules.

To navigate to the module; choose MenuClinicalUtilizationManagementRoutingRules

Creating and Setting up a Routing Rule

After the Routing Rules module is open, click on the Create button.

Benefit Plan:where a benefit plan is selected, or multiple benefit plans to start creating the route. The list that prepopulates in the Procedure Code and Definition fields will only display services and definitions that are currently associated with the Benefit Plan selected.

Proc Code:what you would use to select a single service to compile the new route. If this is used, then the Definition field will be inactive.

Age Group:would you would determine limit routing of SARs by age group. You can only select one age group or ALL ages.

County:what is used to determine the route of the SAR by consumers residing county.

Route Category:Route Category is a MCO maintained field for their own purposes.

Diagnosis Group:used to determine the routing of a SAR by diagnosis group, one group or ALL can be chosen.

User Name:used to determine the staff member the SAR is routed to using the abovie criteria

Patient to Same CM:select this checkbox if the MCO staff has a history of reviewing a consumers SAR, so if the reviewer has authorized services for this consumer before and the additional criteria meet the route, then they’ll repeatedly go to this staff person that meet the predetermined criteria.

Active:when this is checked, then this route is currently in place.

Exclude:when this is checked, then a SAR with the above criteria will NOT be routed to the staff identified in the User Name field.

This example shows what configuring a route looks like when routing by a Service Definition:

The process is the same for both routing by service or by definition. When one is utilized, the other field will becom inactive.

Once we have the route set the way we want it, we can choose the save button. Select the Ok button when the “Inserted Successfully” message appears.

Back at the main screen, a new row will appear with the route you just created along with the others, you can filter for newly created rule as well which is covered later in the document.

Now a route is set for all SARs requesting services that fall under the Definition selected for Med B, for all age groups in the IDD diagnosis group, and consumers from New Hanover County to go to Peter.

**Note: If the Exclude check box is utilzed, then any SAR meeting each of the routed criteria will NOT be assigned to the user indicated. Basically the complete opposite.

Filtering for a Routing Rule(TOP)

It is possible for your routing rule matrix to become complex, to filter for a group of routes that meet a certain criteria, then you’d want to choose the Filter button.

In this example, I’m searching for all of Peter’s Med B routes coming from New Hanover County consumers of thoughs routes that are currently active and both included and excluded routes.

Results:

Updating a Route(TOP)

To update a route, search for the route (or group of routes) by clicking the Select checkbox in the first column, then choose Update.

After selecting the routes to update, choose Update:

From here, I’m going to update the Age Group and the Diag Group for both Routes by clicking and choosing from the dropdown, once finished choose Update:

**If you inactivate a route, you can reenable by filtering for inactive routes and activate it.

Copying a Route(TOP)

If you have a group of staff that need to be routed SARs by the same criteria, then you can set up and create the initial route then select that route and choose Copy.

This will bring you to the screen which is just like Update screen from earlier with the same front end functionality. In this example I’m only copying one rule to John Smith but you can copy a group of rules and copy them to a user (perhaps when onboarding a new employee). Or, if you’re creating multiple rules for a single staff member then you can copy the original and make the desired changes. Choose Update when complete.

Now John has a Rule with the same criteria as Peter. Therefore, the system will disperse these SARs evenly so no one is distributed more than the other.

Organizational Chart Change: there will be situations where staff will move to different departments or job responsibilities. When this happens, it is suggested to incorporate the MCO’s internal procedures to include inactivating ALL routing rules prior to removing the said staff to a different function group. If not, SAR submitters will receive an AlphaMCS error message stating the assignee is not permitted.

Systematic Process Flow(TOP)

Step 1

When a SAR is submitted in the AlphaMCS system, the first thing the routing process is going to do is pull all care managers that have routes set up that meet the submitted SAR’s criteria.

So if a Medicaid B SAR is submitted for service H2022 for an adult out of New Hanover county, then all care managers that have a route that meet that criteria will be carried over to Step 2.

Criteria:

  • County ID in the routing rule equal to the patients county ID, or routing rule county ID is 0 (all counties)
  • PC ID in the routing rule equal to the PC ID from the SAR, or routing rule PC ID IN (1, 0, 99999) (all pc_ids)
  • Age group in the routing rule equal to the patient's, or routing rule age group IN (0, 1) (all ages)
  • DX Group in the routing rule equal to the SAR DX, or routing rule DX = 0 or 1 (all DXs)
  • BP in the routing rule = BP from SAR
  • Routing Rule Active
  • Routing Rule Default user is 0 or null

Step 2

Out of the list of Care Managers defined, the next action taken is the system is going to omit (or exclude) all CMs that have the rule configured for them, but with the excluded checkbox marked.

Step 3

The next step is checking which routes are currently set to Active, an example of a valid rule switching from active to inactive would be if a CM is maybe on vacation that week.

Step 4

The last step is assigning the user. However the last step when a user is defined is conditional with additional variables:

“If there is more than 1 eligible user, then we’ll continue to the conditional checks”

Step 4A

Pick the user who was last assigned to the patient on the SAR. If applies, then pick that user; else go to 4B

Step 4B

Select a random user who has the minimum number of SARs under review

1 / AlphaCM, Inc10/22/2013 3:27 PM