CRITERIA_REVIEW

Description: |
This table contains information about medical necessity criteria reviews. The records included in this table are Criteria Review Records (CRR) records storing items that a case manager would enter in the Utilization Review activity or during a criteria review completed in Tapestry. For example, this includes the review outcome, guideline days, and the time and date the review was completed.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
CRITERIA_REVIEW_ID | 1 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | CRITERIA_REVIEW_ID | NUMERIC | No |
The unique ID of the criteria review record.
2 | CRITERIA_REV_NAME | VARCHAR | No |
The name of the criteria review record.
3 | PATIENT_ID | VARCHAR | No |
Stores the patient the criteria review is for.
4 | OBJECT_TYPE_C_NAME | VARCHAR | No |
The type of record the criteria review is for.
May contain organization-specific values: No
Category Entries:
RFL
5 | REFERRAL_ID | NUMERIC | No |
The ID of the referral that is associated with the criteria review.
6 | REVIEW_ID | VARCHAR | No |
The review ID associated with the criteria review.
7 | REVIEW_NUMBER | VARCHAR | No |
The review number of the criteria review record.
8 | CRITERIA_SET_NAME | VARCHAR | No |
The criteria set name for this criteria record.
9 | CRITERIA_STATUS_C_NAME | VARCHAR | No |
The status of the criteria review.
May contain organization-specific values: No
Category Entries:
Not Met
Met
In Progress
Completed
Acute Met
Critical Met
Observation Met
Alternate Met
Intermediate Met
Not Applicable
Neonatal Intensive Care Level III Met
Special Care Level II Met
Newborn Level I Met
Transitional Care Met
Neonatal Intensive Care Level IV Met
Variance
Partially Met
Ambulatory Detoxification Met
Home Care Met
Inpatient Met
Inpatient Detoxification Met
Intensive Community-Based Treatment Met
Intensive Outpatient Program Met
Outpatient Met
Partial Hospital Program Met
Subacute Care Met
Residential Crisis Program Met
Residential Treatment Center Met
Supervised Living Met
Inpatient Rehabilitation Met
Not Met (Not Selected)
Not Met (Selected)
Met (Not Selected)
Met (Selected)
Level I Met
Level II Met
Level III Met
Subacute Met
Hospital in the Home Met
Day Treatment Program Met
Neutral
Skilled Nursing Facility Met
Behavioral Health Observation Met
SNF Met
Supplemental Medicare Criteria Met
10 | SERVICE_DATE | DATETIME | No |
The service date associated with this criteria review record.
11 | PROVIDER_ID | VARCHAR | No |
The unique ID of the provider associated with the criteria review.
12 | PROVIDER_ID_REFERRING_PROV_NAM | VARCHAR | No |
The name of the referral source.
13 | NOTE_ID | VARCHAR | No |
The unique ID of any notes associated with this criteria review.
14 | REVIEW_STATUS_C_NAME | VARCHAR | No |
Review status for criteria using CERMe (third-party software from McKesson used for utilization review).
May contain organization-specific values: No
Category Entries:
Pending Primary
In Primary
Pending Secondary
Pending Secondary-Medical
Pending Appeal
Completed
In Progress
Waiting For Info
Primary Completed
Secondary Completed
Deleted
15 | PATIENT_CSN | NUMERIC | No |
Stores the Patient Contact Serial Number for the encounter in which the review was created.
16 | REV_TYPE_C_NAME | VARCHAR | No |
Stores the type of review that is performed - Admission, Concurrent, Discharge, etc.
May contain organization-specific values: Yes
Category Entries:
Admission
Continued Stay
Discharge
Preadmission
Outpatient Procedure
Unspecified
Planned Admission
Emergent Admission
Initial Review
17 | ADDITIONAL_NOTES_ID | VARCHAR | No |
Stores additional comments or notes related to the review.
18 | REVIEW_INSTANT_DTTM | DATETIME (UTC) | No |
Stores the instant the review was filed.
19 | CONTENT_SOURCE_C_NAME | VARCHAR | No |
The content provider used for this review.
May contain organization-specific values: Yes
Category Entries:
InterQual©
MCG©
20 | REVIEW_DX_ID_DX_NAME | VARCHAR | No |
The name of the diagnosis.
21 | REVIEW_PX_ID_PROC_NAME | VARCHAR | No |
The name of each procedure.
22 | CRITERIA_OUTCOME_C_NAME | VARCHAR | No |
Final determination of the review.
May contain organization-specific values: Yes
Category Entries:
Approved
Referred for medical review
Waiting for more information
Request withdrawn
Review interrupted
Alternate procedure/referral/LOC selected
Certified
Directed to New Criteria Subset
Discharged with no further treatment
Non-Certified
Not Appropriate
Not Approved
Overturned
Partially Certified
Redirected
Refer to Case Management
Referred for Peer Review
Refer for Secondary
Request Canceled
Appropriate
Clinically stable for discharge
Other
23 | PARENT_REVIEW_ID | NUMERIC | No |
Points to the parent criteria review that generated this review.
24 | REV_DAY_TYPE_C_NAME | VARCHAR | No |
Stores the type of day for this review.
May contain organization-specific values: Yes
Category Entries:
Clinical Indication
Care Day
Extended Stay
Operative Status
Intensive Care
Intermediate Care
Telemetry Care
25 | REVIEW_DAY | INTEGER | No |
Stores the numeric day of the review.
26 | GUIDELINE_DAY | INTEGER | No |
Stores the current Guideline Day for an MCG Optimal Recovery Course.
27 | COMP_INST_UTC_DTTM | DATETIME (UTC) | No |
The time and date a utilization review was marked complete.
28 | COMP_USER_ID | VARCHAR | No |
The user who marked a utilization review as complete.
29 | COMP_USER_ID_NAME | VARCHAR | No |
The name of the user record. This name may be hidden.
30 | REVIEW_SELECTED_YN | VARCHAR | No |
This row indicates whether a patient status associated with a review is the status selected by the user. Selection is relevant for reviews in which the user can check off criteria for more than one patient status such as observation or inpatient, but for which the user must select one target patient status to file the review. If the patient status associated with the review is the selected status, this item is set to Yes. If the patient status associated with a review is not the status selected by the user, it is set to No. If this item is empty, then the review does not have an associated patient status that is either selected or not selected.
May contain organization-specific values: No
Category Entries:
No
Yes
31 | CREATION_REVIEWER_USER_ID | VARCHAR | No |
The reviewer who first created this review.
32 | CREATION_REVIEWER_USER_ID_NAME | VARCHAR | No |
The name of the user record. This name may be hidden.
33 | CREATION_INST_UTC_DTTM | DATETIME (UTC) | No |
The instant at which this review was created.
34 | OVERALL_DETERMINATION | VARCHAR | No |
Textual representation of the overall determination of a review.
35 | REVIEW_VENDOR_C_NAME | VARCHAR | No |
This item stores which criteria review vendor created the review.
May contain organization-specific values: Yes
36 | AUTH_REQUEST_STATUS | VARCHAR | No |
Authorization request status from a third party criteria review vendor.
37 | AUTH_REQUEST_ID | NUMERIC | No |
The authorization request associated with the guideline review.
38 | CREATION_AUTH_REQUEST_CSN_ID | NUMERIC | No |
The authorization request contact associated with the creation of this criteria review record.
39 | RECENT_AUTH_REQUEST_CSN_ID | NUMERIC | No |
The authorization request contact associated with the most recent data in this criteria review record.
40 | GUIDELINE_TYPE_C_NAME | VARCHAR | No |
The type of guideline review. Internal Guideline Review [1] means that the guideline review was created for an internal guideline (GLD).
May contain organization-specific values: No
Category Entries:
External Review
Internal Medical Necessity Review
Administrative Requirement Review
41 | AI_ANSWER_ID | VARCHAR | No |
AI-generated questionnaire answers associated with guideline review
42 | VENDOR_AGENCY_ID | VARCHAR | No |
The guideline review vendor that created the review as a unique record ID instead of a category.
43 | VENDOR_AGENCY_ID_AGENCY_NAME | VARCHAR | No |
The name of the agency.
44 | ASSOCIATED_DATES_FROM_DATE | DATETIME | No |
If the review is associated with dates of a patient's stay, this is the beginning of the date range.
45 | ASSOCIATED_DATES_TO_DATE | DATETIME | No |
If the review is associated with dates of a patient's stay, this is the end of the date range.
46 | UPDATE_INST_LOCAL_DTTM | DATETIME (Attached) | No |
Stores the instant the review was last updated in the local (patient encounter) time zone.
47 | DAYS_OF_CARE_START | INTEGER | No |
For a progression plan review, this item is the numeric representation of the first day this review covers of the patient's stay, with the day the progression plan began considered day 1.
48 | DAYS_OF_CARE_END | INTEGER | No |
For a progression plan review, this item is the numeric representation of the last day this review covers of the patient's stay, with the day the progression plan began considered day 1.
49 | DAYS_OF_PROGRESSION_PLAN_START | INTEGER | No |
For a progression plan review, this item is the numeric representation of the first day in the progression plan this review covers.
50 | DAYS_OF_PROGRESSION_PLAN_END | INTEGER | No |
For a progression plan review, this item is the numeric representation of the last day in the progression plan this review covers.