Appeal is to Banana
Aggrieve to Disaggrieve?
Definitions and Turnaround Times
A Bowl of Mixed Nuts
Should I or Shouldn't I?
100
Give an example of an appeals call you might receive
Rx Denial, Referral/Auth denial, etc.
100
You submitted a grievance for Shelly, she didn’t have the bills that she’s disputing at the time. Shelly emailed you the bills in question. Now that you received the bills, what is your next step?
To upload the bills to the grievance SR and set a task for the A&G Coordinator, so that they are aware you’ve uploaded them.
100
Define an exempt grievance
Member expresses dissatisfaction on an issue, MSR is able to resolve the issue within 24 hours (1 Business day)
100
When should you submit an appeal VS a grievance?
When there is a denial is when you would submit an appeal VS a complaint
100
Should you submit an Appeal or Grievance?
Mom of a 26 year old member calls in about a bill member received for a claim that was denied
IF AOR/PHI form is on file, if not then no
200
Jamie from Dr. Tang's office wants to submit an appeal for a Rx denial is an AOR form needed to submit this?
No AOR form is not needed
200
Name three things that set an exempt grievance apart from the other categories of grievances
1. Exempt is resolved by MSR, others are resolved by A&G
2. The Turnaround time is within 1 BD
3. There are extra steps an MSR must take in order to submit the grievance to A&G for review
200
What is the turnaround time on a routine grievance and how long does it take for A&G to send out an acknowledgement letter?
30 calendar days/5 days
200
Member calls in and tone matches this expression, you are able to calmly explain why the bill is the amount charged. Member takes your offer to warm transfer to billing to make a payment. Does a grievance need to be filed, if so what type?
Yes, an exempt grievance
200
Should you submit an Appeal or Grievance?
A prospective member is trying to fill out an IFP (Individual Family Plan) application online and is upset with all the technical issues he's gone through. You are able to help the caller complete the application. Would you submit an Exempt, Routine grievance or nothing and why?
Nothing, this is not a current member.
300
What information is important to document when submitting an Rx appeal?
The usual information:Member's name, member#
Rx Information:
Name of medication
Dosage:
Prescribing Dr.
Day supply (30 day, 90 day)
Denial Reason:
(If caller has)ESI Case#
· Are they out of medication
o If No, how much do they have left
o Name of Pharmacy:
300
Member Call:
Celeste wants to change her PCP, when you ask for the reason she explains that Dr. Jones was very rude during their last visit and condescending.
You offer to file a grievance, but Celeste declines “I don’t want to stir up trouble, I just want to change my doctor.” Would you file an exempt or routine grievance? Are there any extra steps you should take?
You would file a routine grievance and notate that member declined to have a grievance submitted on her behalf. Advise member that we will need to submit this to our quality team for an internal review, because we want our members to have the best care.
300
What is the turnaround time on an expedited grievance?
72 hours
300
When a member wants their open routine grievance changed to an expedited grievance, what should you do?
Create a new Service Request. You cannot change an open SR from Routine to Expedited.
300
Should you submit an Appeal or Grievance?
Wife calls in to appeal a denied claim, there is no PHI on file but member is incapacitated.
Yes, ask wife for copy of the Power of Attorney
400
What are all the steps to submit a Rx appeal, when the call is from a provider?
Document all needed information in the IL under the provider and save. MSR MUST open new IL under member, copy and paste information on IL and open appeal service request on member's account in Sales Force.
400
Name all five reasons you would submit an expedited grievance
- Imminent and serious threat to the health of the enrollee
- Severe pain
- Potential loss of life, limb or major bodily function
- Cancellations, recissions or non-renewals
- Member requests the grievance be expedited/urgent/escalated
400
What does DMHC stand for and what are they?
Department of managed healthcare, they are a department that govern over the HMO policies of CA
400
What are two things additional you need to advise the member when you file an expedited grievance:
- Member’s right to file with DMHC, give the phone number
- That if this does not meet expedited criteria, the priority may be changed to routine which has a 30 day TAT
400
Should you submit an Appeal or Grievance?
Husband calls in for his wife to submit an appeal for a denied referral, you see in Heathrules that the PHI form member signed limits husband’s access to claims only.
No, an AOR form is needed or wife will need to give permission for the appeal to be submitted
500
Luis from Dr. Armstrong’s office is calling to submit an appeal on a denied referral. You see that member has already submitted an appeal, what information can you review with the provider?
If no AOR/PHI on file, MSR is to advise that per HIPAA we would need to have either form on file or verbal authorization from member to review the information with the doctor's office.
500
Member wants to put in a complaint that she’s having difficulty getting reimbursement for a behavioral health claim, what are your next steps?
Apologize to member and advise that behavioral health complaints are handled by Optum, warm transfer member for further help.
500
What does SBAR stand for and how would it be beneficial to use during a grievance or appeal?
SBAR means Situation, Background, Assessment, and Recommendation.
It’s beneficial to use this to have all the information needed for a member’s appeal or grievance to be reviewed.
500
Member is being denied prior authorization for future home health visits, but member is unable to perform Activities of Daily living on his own. Would this be a routine appeal or expedited?
An expedited appeal
500
Should you submit an Appeal or Grievance?
Dad is not on the SHP policy, no PHI form on file but wants to submit a complaint for daughter who is 6 years old about the care she received.
If dad can verify 3 pieces of information about the member, he is able to act as member’s personal rep and submit a grievance.