New Auth or HP Appeal
Member has a new significant event/diagnosis.
Answer: New Auth
What diagnosis excludes pt from EOB?
Answer: COVID
True or False. ALL Hospice auths go to the MD?
Answer: True
SNF A and SNF B request simultaneously?
Answer: Void/Void
True or False? PSC MUST have a verbal confirmation from requester in order to withdraw auth?
Answer: False. Written or Verbal. Okay to use nH messenger or leave on secure voicemail.
Denial without P2P completed. MD now wants to call in for P2P.
Answer: HP Appeal
How many days remaining would a pt need to NOT need an EOB IDN Letter?
Answer: 8 days or more
Pt revoked hospital on Dec 25th. When can a provider submit a new auth?
Answer: January 1st
SNF A approved, SNF B requests?
Answer: Void/Void
Requester askes to withdraw due to pt being medically unstable in acute. Do you need a dismissal letter?
Answer: Yes, dismissal letter is required.
Member denied due to not stable for D/C. Becomes stable for D/C.
Answer: New Auth
How many days notice from the LCD will a member have before EOB begins?
Answer: 2 days
Withdraw or Void? Hospice auth without new diagnosis prior to the first of the following month?
Answer: Void
SNF A approved, SNF B requests what is the decision type? Data Entry Not Valid or Member Not Eligible?
Answer: Data Entry Not Valid (Duplicate Auth)
Pt has 2 pending SNF facility. Per acute CM pt is to D/C to SNF A. Do you need a dismissal letter for SNF B?
Answer: No, void/void as duplicate auth.
Denied due to lack of clinical. New request received with updated clinical.
Answer: HP Appeal
How many days left to be considered partial EOB?
Answer: 1-7 days
Advise provider to keep billing whom until the first day of the following month?
Answer: Traditional Medicare
SNF A auth cancelled. Pt did NOT admit to SNF B during auth window?
Answer: Void/Cancel
Auth is DENIED by MD, requester wants to withdraw. Do you need a dismissal letter?
Answer: No, ONLY applies to auths that do NOT have a determination.
NOMNC issued and SNF requests a new auth. Member has a change from NWB to WBAT LLE.
Answer: New Auth
How many negative days over EOB should you reach out to your CTM?
Answer: 20 days
Give an example of a hospice rule exception
Answer: New diagnosis unrelated to hospice diagnosis. (IE new hip fracture)
Pac A approved. Pt D/C home?
Answer: Void/Cancel
Requester calls to withdraw after third clinical request which standardized template do you use?
Answer: Medical Instability.