Purchased/Referred Care

RRM Category: ADMINISTRATION

Overview

The RRM Purchased/Referred Care (PRC) staffing module estimates the requirements for PRC staff to include: PRC Supervisor, RCIS Data Entry Clerk, Utilization Review Clerk and PRC Staff. The PRC staff performs the day-to-day management functions of the contracted health services program for the facility. The workload parameter that is the key variable is number of PRC authorizations for health care for eligible individuals.

Services Description:

The PRC staff performs the following activities:

• Patient eligibility for Purchased/Referred Care
• Processing procurement orders for requested contract health services
• Tracking allocation of PRC funds to assure the program stays within budget
• Coordination of activities associated with contract health care

Staffing Criteria

Fixed PRC Manager staff of 1.0 FTE for each facility that processes 50 or more PRC authorizations for health care services.

Fixed RCIS Data Entry Clerk of 1.0 FTE for each facility that uses RCIS for automation of referrals.

PRC Staff of 1.0 FTE for every 700 PRC authorizations for health care services at facilities that have over 50 PRC authorizations a year.

NOTE: In order to consider the time it takes to process PRC denials the authorization driver has been reduced to reflect this work load. This is based on a review that showed that authorizations and denials at a facility are similar.

Utilization Review Clerk OF 2.0 per facility

Staffing Formulae

Personnel Categories:

PRC Manager
RCIS Data Entry Clerk
PRC Staff
Utilization Review Clerk

Driving Variables:

PRC Authorizations

MINIMUM STAFFING LEVELS (fixed):

Personal Category	FTEs	Per	Driving Variables	Min.	Max.
PRC Manager	1	Per facility		50
RCIS Data Entry Clerk	1	Per facility		50

Plus, VARIABLE STAFFING LEVELS:

Personal Category	FTEs	per	Driving Variables	Min.	Max.
PRC Staff	1	700	PRC Authorizations	50	n/a
Utilization Review Clerk	2		Facility