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Critical Incident Report Form
CRITICAL INCIDENT REPORTING INSTRUCTIONS
- At onset of an incident, notify your supervisor; your supervisor will need to confirm with Dr. Craig Pierce, at (505) 604-4589, to determine if a situation is considered “Critical.”
- If confirmed to be a Critical Incident, you must report the incident within 24 HOURS to the appropriate persons and agencies. If you need further assistance, please contact Raana Azad at (505) 205-5641.
- First verify if your client has one of the following valid Codes of Eligibility (COE) in the NM-HSD Medicaid Portal: 001, 003, 004, 081, 083, 084, 090, 093, 094, 095, 100w/NFLOC, 200w/NFLOC, only 1/10 SWFGC clients.
- If YES, you will report the critical incident to the following website: https://criticalincident.hsd.state.nm.us; using SWFGC username and password, submit report online and store the confirmation number provided to you on the NM-HSD site
- If NO, which is true for 90% of our clients, follow the instructions below:
- Verify the client’s funding source or the correct MCO.
- DOWNLOAD AND COMPLETE FORM using Internet Explore or use this link CIR Form (Sept 2018)
- Right-click on the above link to the document
- Select “Save Target As” or “Save Link As”
- Save the document to your hard drive
- Open with Acrobat Reader
- After CIR Form is completed and reviewed by supervisor, fax to the appropriate Managed Care Organization (MCO), and all other entities involved that are listed on this HSD Form.
ACS-Medicaid (505) 827-3126
Presbyterian Healthcare/Magellan (505) 843-3011
Blue Cross Blue Shield (BCBS) (972) 766-3320
Western Sky/ Centene TBD
United Healthcare (866) 751-2449
Optum Healthcare (Non-Medicaid) (877) 950-9545
Molina Healthcare (855) 260-8737
- Upload electronic copy of the completed CIR into client’s electronic health record (i.e., Welligent), and print a copy and file into client’s chart.
- Submit electronic copy of the completed CIR to Lori Tseng, Quality Assurance Manager, at firstname.lastname@example.org