Requests can be routed for a Quality Control review after being submitted from Fulfillment.
Two kinds of users can work Fulfillment Quality Control requests:
o Users with the QA Reviewer role, assigned in Platform Administration. These users can ONLY open Fulfillment Quality Control requests. They cannot search for or work on requests in any other status.
o Users with the Fulfillment QC permission. This permission can be assigned to any HealthSource Clarity user by the Applications Support Management (ASM) team. These users retain all the “parent” rights of their role and gain the ability to work on Fulfillment Quality Control requests.
If you don’t have the QA Reviewer role or the Fulfillment QC permission, you can still search for and open Fulfillment Quality Control requests, but they will be displayed in read-only mode.
The following flowchart shows the different ways by which a request passes through these two statuses:
o QC in Progress
o Fulfillment Quality Control
These rules determine if a request is sent for an automated Quality Control review in the first place.
Depending on the automated results, the request can then be sent for manual review or to the next “normal” step in the workflow, such as delivery.
Rule |
Default condition |
Options |
Delivery Method |
If the request uses an Onsite Delivery Method, it is NOT routed to Fulfillment Quality Control. Because the CSR sends or gives these Medical Records to the requester, there is no point in sending them for review. |
|
Site |
All Sites are enabled for Fulfillment Quality Control by default. |
Can be disabled for a specific Site. |
Requester Type |
Enabled, except for: o Direct Payor (PAYD) o Indirect Payor (PAYI) o Government (GOV) o Continuity of Care (COC) |
Can be disabled for a Requester Type. |
Requester ID |
Enabled for all requesters, except for the excluded Major Classes listed above. |
Can be disabled for a specific Requester ID. |
Suspected Conflicts found |
Did the automated Fulfillment Quality Control review find suspect data on the Medical Record pages? Yes — routed for manual review. No — sent to the next step in the request workflow (certification, invoicing, delivery, etc.). |
Requests can be forced to manual review, regardless of the automated results, based on: o Site o Requester Type o Requester ID |
When Fulfillment Quality Control automatically searches the Medical Records, it looks at these values:
o Patient Name
o Patient Date of Birth
o Dates of Service
Any mismatch between the values found in the Medical Records and the values entered on the request are flagged as Suspected Conflicts.
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The character recognition (OCR) and Natural Language Processing (NLP) tools used during automatic evaluation can cause: o False negatives — Correct values flagged as suspects o False positives — Incorrect values not identified as suspects You must still review the Medical Records for requests sent to Fulfillment Quality Control.
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1. Log in to HealthSource Clarity as a user with the QC Reviewer permission.
2. On the Request Search page, click Work Next.
3. The request opens, with the Request Letter displayed in the Document window on the left side.
4. Do you see a Review Suspected Conflicts notification at the bottom of the Data Entry window?
a. Yes — Go to Step 5.
b. No — The automated review did not find possible conflicts, but the request was forced to manual QC review anyway.
5. Click the Review Suspected Conflicts notification.
6. The screen changes to the Fulfillment Quality Control view, showing you the Medical Records, Patient Information, and the list of Suspected Conflict Items.
7. Click Highlight Suspects for the first Suspected Conflict Item. The suspect data is highlighted in the Medical Records.
a. If the suspect data was found on multiple pages, click Next / Previous until you have reviewed all the places on which it was detected.
8. Review the Patient Information and decide how to proceed.
a. You may need to check the Request Letter to find exactly what was authorized.
b. Check with your supervisor if you have questions about how to proceed. These instructions are more technical (how-to) than operational (why-to).
Action |
Result |
Use when |
Delete Pages |
Deletes EVERY page on which the suspect data was found. You CANNOT undo the deletion of pages. |
The Medical Record page clearly was not requested — it reflects the wrong Patient and / or the wrong Dates of Service. In some cases, you may want to Ignore the suspected problems rather than delete the pages. For example, you may want the CSR to be able to see the “wrong” pages so they are not captured again. |
Ignore Items |
Leave the pages in the Medical Records. This action effectively means “I looked at the suspect item and it is not a cause for concern.” |
The suspect item is NOT the Patient Name, Patient DOB, or requested Date of Service. For example, a doctor’s name may be flagged as a suspect. |
Patient Name, Patient DOB, or Date of Service is in a different format than expected but the Medical Records still meet the request. For example, the Request Letter may refer to Jane Doe, while the Medical Records are for Janet B. Doe. You might also see simple typos (mistakes) flagged as suspects. If this happens, use other patient identifiers (DOB, Account, Case, etc.) to verify that the correct Medical Records were captured. |
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The patient information was entered incorrectly during Logging or Fulfillment. |
9. Provide a Reason for Deleting or Reason for Ignoring:
Reason popup |
Reason |
Use when |
| Reason for Deleting | Incorrect Patient |
Medical Records belong to the wrong patient. |
Incorrect DOB |
Medical Records belong to the wrong patient. |
|
Unauthorized DOS |
Medical Records cover Dates of Service not authorized by the Request Letter. |
|
Other |
You must provide details to explain why you deleted the pages. |
|
Doctor / Nurse |
The name belongs to a health care practitioner, not the patient. |
|
Maiden name |
The name reflects the correct patient but the Medical Records come from a time before the patient’s name was legally changed. |
|
Medical Terminology / Verbiage |
Medical word(s) flagged as a person's name, usually because of capitalization. For example, Advil is often capitalized and may be mistaken for a name. |
|
Not a DOB |
The suspect date value is something other than the patient’s Date of Birth. For example, it might be a date of treatment. |
|
Not a DOS |
The suspect date value is something other than a Date of Service. For example, it might be a Date of Birth or a dated comment. |
|
Other |
You must provide details to explain why you ignored the suspect data. |
10. The first Suspected Conflict Item is marked with a green checkmark.
a. If you deleted pages, and those pages originally contained other suspect items, the “later” suspects will be removed from the list.
b. Click Revisit Items to “undo” the Ignore Items command. You cannot use Revisit Items to restore pages that you deleted.
11. Repeat Step 8, Step 9, and Step 10 until you resolve everything. At that point, the background of the Suspected Conflict Items window turns green.
12. Do the Medical Records now meet the requirements of the Request Letter?
a. Yes
b. No
You may open a Fulfillment Quality Control request and see no Suspected Conflict Items.
When this happens, the request was pushed to the manual Fulfillment Quality Control step by a business rule, not because possible problems were found.
1. Review the Request Letter, Medical Records, and Patient Information.
2. Do the Medical Records meet the requirements of the Request Letter?
a. Yes — Submit and Next.
b. No — Return to Exceptions.
In some cases, Fulfillment Quality Control may identify possible suspects because of data entry errors during Logging or Fulfillment. For example:
o the Patient Last Name typed incorrectly as “Jonhson” during Logging.
o The automated review finds a Suspected Conflict on every Medical Record page that included the correct name, “Johnson.”
If this happens:
1. Change the incorrect value in the Patient Information section of the Data Entry window. The Suspected Conflict Items message is NOT updated — we don’t push the request back through the automated Fulfillment QC review.
2. Ignore the suspects that were caused by the data entry error. Use the Other reason and explain that the problem was caused by a data entry mistake.
3. Review the Medical Records for any other potential problems.
4. Submit the request.
Can a request go to Fulfillment Quality Control only one time?
I changed the Patient Name but it still shows as a conflict.
I opened a request and there were no Suspected Conflict Items.
Does Fulfillment Quality Control slow down the delivery of a request?
