Urgency
Watch out for
Admin Cases
External
Reminders
100
tat for Urgent commercial appeal request
What is 72 Hours
100
We look here in 360 to see if an appeal can be added to the case.
What is look under update case for add appeal.
100
The product is for an admin case.
What is admin benefit review.
100
We can do an external appeal after these reviews have been completed.
What is after a denied level 2 or denied urgent level 1 appeal.
100
these are always done with every case
what is Hipaa is verified// give monitor disclosure statement coverage check is ran search c360 via member id number verify the name of medication, strength qty and day supply Always ask rep transferring call if call is fully authenticated
200
Standard Medicare appeals are processed within
What is 7 days
200
This is the number of pieces we need to verify hipaa.
What is three pieces.
200
when a medicare primary case and a quantity case is required
what is a medicare dual edit review
200
We look at this to make sure that the external appeal is offered and that ESI handles it.
What is denial letter to doctor under case documents. (Entire Case Activity in 360)
200
We do this when we have an appeal request in q que, and there is an open appeal in 360. (3 things)
What is attach NEW images, if urgent set urgency, and if MCMC upload images to their site and email team 5.
300
This carrier is a high priorty one and we always email the ADC Clinical Appeals Team when we get it.
What is carrier 6529.
300
The number of days we have after the denial to build and appeal. (commercial and medicare)
What is 180 days and 60 days.
300
you will use this to determine if an appeal should be initiated or build a new case
what is decision grid
300
An external appeal can only be started if we see this on the fax images.
What is the external appeal form or it must say external appeal somewhere on the faxes.
300
We check all new images for this before attaching to a case or sending images to another que.
What is relevant information to start an appeal with or new date or appeal request if duplicate information.
400
This is the date and time we use to set urgency.
What is the date and time the fax/appeal was received stating urgency.
400
We do this with every case to make sure the plan still requires a pa.
What is a coverage check.
400
You will do this if MCMC handles the appeal.
What is start appeal and send packet to MCMC as an appeal.
400
We go to this location to update the prescriber information
What is update case>update prescriber
400
Do this when you are unable to find a carrier on the MCMC website (two things).
What is check with a fellow appeals rep to take a second look and if not there send an email to the UM Box that the carrier cannot be found. Bonus: What do you do with images or case then?
500
We do this if the case has add primary and faxes are urgent.
What is build a shell.
500
We see this as soon as we open the case in 360 and know immediately that a new case is needed.
What is blue messaging for member not eligible
500
You will know if the faxes on the case were used for the primary when you see this.
What is the same name that attached the faxes completed the primary (forgot to fax process so is sent to appeals).
500
This goes in the subject line in the email sent to the UM Box.
What is Urgent/Standard External Appeal (carrier) patient name medication name date and time of request (from faxes).
500
We should always do this if there is no information in ESD or 360 as to who handles the appeal.
What is reach out to the UM Box either via IM or email. Bonus: Why?
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