Documents
What is one of the main documents that is required on all dental cases?
EOC
What appellant/s gets the verbal acknowledgement call?
Member/AOR/POA
Q3 - Required document missing for MD review
What type of is this "I'm suffering from short of breath due to the current weather conditions (Sahara Dust) I need my oxygen tank to be approved ASAP"
Expedited Appeal
What should the contact method reflect in CGX?
CCP2
What is the name of the document that is used to determine the subtask categories in MHK?
Medicare Advantage (MA) and Dual Demonstration Clinical Review Procedure
Is a medical records outreach REQUIRED on all cases?
No. This is a not a mandated requirement.
What is the error code for a case that was worked as expedited and did not contain any expedited verbiage nor keyword and what question number would this affect?
Q1 - Priority incorrectly identified.
All DME appeals are auto expedited.
False/Incorrect
What information in the claims payment notes is required for an outpatient surgery?
GA MD Overturn
MD Response (if applicable), User ID, and G&A Reference number
The Ops associate is missing the auth history screenshot from the case, what reference document would you used to in your downscore rationale to the associate?
Gov’t Programs MR & Supporting Doc Decision Tree/Naming Convention
It's a member appeal, who gets the notified of resolution call?
Member
Identify three (3) auto expedited appeal types?
Home Health
Skilled Nursing
Inpatient Rehab Facility
Inpatient Behavorial Health are now considered pre-service appeals.
No, as of April 24, 2025, all Inpatient Behavorial Health cases are considered auto expedited even if the member is discharged.
The associate documented the casenote as "Requester's phone and address obtained from appeal". Is this correct if no, what is missing?
No, this is documented incorrectly as the actual address was not notated.
What document you used to reference your inpatient status missing case note?
Medicare Advantage (MA Expedited Appeal Preliminary Review
What is the contact outcome if AOR gets the notified of resolution by voicemail from the Humana associate?
Notified of resolution
How do you identify the appeal priority on a phone appeal to determine if the request is for expedited or pre-service?
Case comments / Rationale
The provider is appealing the denial for a Home Health and stated in the appeal letter that they are requesting a standard appeal; how would you treat or audit this appeal?
The service is an auto expedited service and will work in this priority despite the 'standard' request in the appeal.
What system would you used to check for an appeal that is untimely?
CGX
What two documents are used on both pre-service and expedited appeal cases?
Clinical Guidance Exchange (CGX) 2.0 Procedures
Medicare Advantage (MA) and Dual Demonstration Clinical Review Procedure
What are two contact outcomes documented on an expedited appeal that is NOT used in any call types?
Left voicemail/message
Completed
Where in the pre-service/expedited AssurX would you find your recent calibration scores?
The calibration tab
What question number from the AssurX audit form speaks about "Was the Case File for MD Review compiled and sent appropriately? " And identify one error that is recorded at this number.
Q4 - Incorrect subtask utilized etc
How you verify that the effectuation date in MHK for an overturn IPA case is right?
The response date/time from the email attachment received on case.