Authorizations Denials and Appeals Flashcards
Who is typically reviewing at the second level of appeal?
* A reviewer at the insurance company
* An arbitrator
* Attorney adjudicator or Administrative Law Judge
* Federal District Court
an arbitrator
Which of the following is helpful to prevent the need to initiate an appeal?
* Inform the patient of prior authorization
* Research the plan’s website
* Not much can be done
* Call the physician
research the plan’s website
Where can forms and documentation related to the appeals process for specific plans be found?
* The physician’s office
* By mail after calling the company
* On the health plan’s website
* Through the government’s website
on the health plans website
What recourse does a Prior Authorization Specialist have if a claim is denied?
* Unfavorable reconsideration
* Re-examination request
* Denial overturn
* Nothing
A re-examination request
Which of the following is an example of when a denied authorization is worthy of appeal?
* Medical criteria does not exist for the given location
* No corollary between this treatment and other areas of the body
* Comorbidities or physical differences make the case exceptional
* Clear communication of denial reason
Comorbidities or physical differences make the case exceptional
What needs to go into the Additional Comments section of the appeal?
* It is not needed and can be skipped
* Any information on why you’re appealing
* Information about the patient
* Details about the diagnosis
Any information on why you’re appealing
What information is NOT typically reviewed by the medical officer?
* Medical records
* Documentation from provider
* Payment receipts
* Diagnosis
payment receipts
Which of the following must be included in the appeals letter?
* The explanation of benefits
* The amount of time between denial and now
* Who the physician is
* What you are asking the insurance company to do
What you are asking the insurance company to do
What happens if a provider fails to submit required information to the insurance company?
* Case can be continued as usual
* Case can be continued with special authorization
* Case can be denied and a new request may be submitted
* Case can be denied and no new request is permitted
Case can be denied and a new request may be submitted
What is the difference between first-level appeal and second-level appeal?
* First-level appeal takes longer than second-level appeal
* First-level appeal is done internally through the insurance company, and second-level appeal is done externally
* First-level appeal requires less documentation than second-level appeal
* Additional detail is required before a case can be brought to second-level appeal
First-level appeal is done internally through the insurance company, and second-level appeal is done externally
