Program Exclusion Review Process

Exclusion Review Process Q&A

1. When will I be able to talk to someone?
   • Answer: “A Medical Assistant will reach out to you in Chat within 24 hours during business days. They will help you understand what comes next.”
      
2. Why has my program been paused?
   • Answer: “After looking at your account, I can see that your program was paused pending further review. You can check the review status in the app. At the top of your Home screen, look for the big blue box with the words “Program paused. Learn why and next steps.” Tap “Learn more” in the bottom right-hand corner of that box for more details.”
     
     If the member is dissatisfied with this answer:
     “Please direct any further questions to the Chat. A Medical Assistant will review your message within 24 hours on business days to answer your questions. They may ask you to schedule a video call so they can gather more info about your medical history.”
      
3. How do I schedule a session?
   • Answer:
     First, check if scheduling is possible on the Health Guide Platform.
     
     If scheduling options show:
     “I’d be happy to schedule you with one of the Medical Assistants reviewing your case. Is there a date and time that works best for you to meet?”
     
     If scheduling options do not show:
     “While your case is being reviewed, if you’d prefer to meet with a Medical Assistant in a video call to go over the details, please let them know in Chat. They’ll be able to set that up if it would help to speak instead of message.”
      

4. I already met with a Medical Assistant, but I was removed from the program anyway. This is unacceptable, I demand an exception.
   • Answer: “I understand how frustrating this must feel, especially after you’ve already met with a Medical Assistant. After a full clinical review, our Medical Review team determined that the Vida telehealth program isn’t a safe fit for you. We apologize for any inconvenience and are happy to pass on any feedback about your experience.”
      

5. I’m still waiting to hear back about my program. How long will it take to get a final decision?
   • Answer: “If the Medical Assistant requested that you upload supporting documentation, after you have uploaded that to your Documents section, they will review your case within 7 business days. For complex situations, our Medical Review team may need to review your info and speak with your regular doctor.  They’ll make a final decision within another 15 business days. If you have any questions in the meantime, please send a message in Chat and a Medical Assistant will respond within 24 hours during business days.”
      
6. I was removed from Medical Weight Loss, can I be placed back in the program?
   • Answer: 
     First, check Medical Weight Loss Chat messages.
     
     If MWL program is marked as ‘complete’ and member received Chat stating program ended because they met exclusion criteria:
     “It looks like we stopped that program for you as it’s not a safe fit given your medical history. Do you see a letter in the documents section of your settings titled ‘Letter of Resolution’? You’ll find more information there.”
     
     If program is paused, and member received “We’ve noticed something about your health history that we’d like to review” Chat:
     “Your program is paused for clinical review. You can reach out in Chat if you have any questions, and a Medical Assistant will respond within 24 hours during business days. 
     
     You can also find out more by tapping ‘Learn more’ on the ‘Program Paused’ content card on your Home screen.“
      
7. My program was put into review and then I had to send a note/signed form from my doctor. How long will it be until that document is approved?
   • Answer: “Thanks for sending in your doctor’s note — it’ll be reviewed within 5 to 7 business days. If the Clinical Team needs to take a closer look after that, a Medical Assistant will follow up to explain the next steps.”

How to Check Exclusion Reason:

• Open Vida Admin from Okta tile
• Click “Member exclusion status” under OOE
• Add member UUID into search, click ‘🔍’
• Take Note of:
  • Status (where in process, see definitions below)
  • Resolution (outcome of review)
  • Exclusion responses (reason for exclusion)

Status Definitions:

• Unreviewed: The member will be in the Unreviewed group in the Exclusion Dash. The MA should begin to look at the case.
• In Review: The member will be in the In Review group in the Exclusion Dash. The MA must mark the Members' Exclusion Responses in order for a decision to be made.
• Awaiting clinical QA review: The member will be in the In Review group in the Exclusion Dash. The case has been submitted to Clinical to review.
• Needs documentation: The member will be in the In Review group in the Exclusion Dash. The member must go to an external provider and have them fill out the form and upload it in the dash.
• Awaiting documentation review: The member will be in the In Review group in the Exclusion Dash, and the member has submitted documentation about their case. The MA needs to review the documents and make a decision.
• Reviewed: The member will be in the In Review group in the Exclusion Dash. The MA must mark the Members' Exclusion Responses for a decision to be made.
• Awaiting decision resolution: The member will be in the Resolved group in Exclusion Dash, and the decision has been made about what’s appropriate for the member. The MA must submit the snippet to kick off the resolution.
• Complete: The member has left the Exclusion Dash and decision has been finalized

Training material:

• Recording: https://drive.google.com/file/d/1HOnBQZeBXaoVsIzLH3cDxWu0CS45CTtx/view
• MS-facing slides:  https://docs.google.com/presentation/d/1YEQgGOyyOk0Groiop5YRTvWfWswbR4MkDg5DS32EIzM/edit?slide=id.g36f85bdc715_0_153#slide=id.g36f85bdc715_0_153