Medical Services
This medical procedure uses a flexible camera to examine the large intestine and is commonly used to screen for colon cancer.
What is a colonoscopy?
After submitting a prior authorization request, this action involves checking the status with the insurance company if no response is received.
What is a follow-up?
This type of review is requested when waiting the standard timeframe could seriously jeopardize a patient’s life, health, or ability to regain function.
What is an expedited (urgent) review?
This organization frequently performs utilization review for labor funds and requires direct authorization submission.
What is Hines & Associates / Valenz / Conifer?
All steps are completed, but notes lack clarity and cannot be understood by another team member.
What is poor documentation?
This diagnostic procedure uses a flexible tube with a camera to examine the digestive tract and help identify issues like ulcers or inflammation.
What is a diagnostic endoscopy?
A provider disputes a pending status, and you respond internally using this structured communication method within the patient chart rather than external outreach.
What is sending an in basket message?
To justify expediting, providers must often submit this type of supporting information explaining medical urgency.
What is clinical documentation (or medical records)?
This type of health plan often provides limited coverage, such as fixed indemnity payments, rather than full major medical benefits.
What is an American Health Plan (limited benefit plan)?
A rep checks eligibility but ignores that the patient has a secondary plan listed.
What is missed coordination of benefits (COB)?
Many procedures like colonoscopies and minor surgeries are performed in this type of healthcare facility designed for same-day care.
What is an Ambulatory Surgery Center (ASC)?
Coverage discrepancies between payer response and patient records trigger involvement from this team to reconcile the information.
What is the registration team?
This type of provider may require additional review or approval before services are covered.
What is an out-of-network provider?
This company manages specialty services like imaging and cardiology reviews and often processes authorizations separate from the health plan itself.
What is Carelon?
A provider requests proof that authorization was granted; this document serves as confirmation of medical necessity approval.
What is an approval letter?
This service focuses on diagnosing and treating skin conditions like acne, rashes, or moles.
What is dermatology?
This type of process eliminates the need for manual reviewer intervention when criteria are met.
What is automated prior authorization?(EMPA/Humata)
This is the formal process of requesting a review of a denied authorization decision.
What is an appeal?
This type of identifier is critical when verifying BCBS coverage because it determines the home plan and billing routing.
What is the alpha prefix (on BCBS ID cards)?
A rep verifies the patient’s plan as active, but fails to confirm whether the provider participates, leading to higher patient costs and potential denial issues.
What is network status (in-network vs out-of-network)?
Even if insurance approves it via portal, this must still be confirmed before scheduling the procedure.
What is eligibility and benefits verification?
A provider schedules at Elmhurst Hospital, but authorization was obtained for DMG Surgical Center.
What is incorrect POS (place of service)?
This option is usually faster and involves direct discussion instead of formal written review.
What is a peer-to-peer (P2P)?
A provider verifies benefits and is told “no auth required” from the health plan. Later, authorization denial occurs because of a delegated vendor. What key mistake occurred during verification?
What is failure to check third-party utilization management vendor (e.g., eviCore, AIM/Carelon, Cohere)?
Failing to secure patient information or discussing it with unauthorized individuals is considered a violation of this
What is HIPAA?