Source Area
An elective/scheduled procedure was pre-certed/authorized for OP surgery but the pt was admitted as IP and IP claim billed
What is Utilization Management
50
What is medical necessity
A claim denied for no authorization. The denial letter stated the authorization was denied for medical necessity due to no documentation being submitted for review.
What is Medical Necessity: Clinical/Records not received
A claim denied for medical necessity.
What is Medical Necessity: Payer Policy
For the Mid-American Region, what Med Nec Tool does Sunflower Medicare use?
What is InterQual
Payer denies claim stating auth dx does not match dx billed on claim
What is Payer
197
What is no authorization
A claim denied due to the authorization being denied at time requested. Account notes stated that the authorization was denied for medical necessity.
What is Medical Necessity: Payer Clinical/Medical Policy
A claim denied for no authorization. There is proof of a valid and approved authorization for a core needle biopsy. The operative note indicated that a fine needle biopsy was successfully completed as planned.
What is Authorization: Pre-Authorization obtained for incorrect procedure
True or False
BCBS Anthem Commercial plans for the Rocky Mountain Region allow two levels of appeal.
What is True
Auth required by payer for elective procedure/diagnostics yet no documented authorization on file prior to date of service
What is Consumer Access
39
What is auth denied at the time of request?
A claim denied for no authorization, but there is proof of a valid and approved authorization on file.
What is Authorization: Precertification not submitted timely
A claim denied for medical necessity. A denial letter specifically states the services could have been provided in a lower level of care such as Observation/Outpatient services.
What is Medical Necessity: Inpatient vs Observation
For the Great Lakes Region, what is the Corrected Claim Timeframe for Wellcare?
Claim is denied related to payer readmission policy
What is payer
55
What is an Experimental/ Investigational denial?
A claim denied for medical necessity. The payer is a Medicare Advantage (MA) plan. The denial letter states the inpatient services could have safely been provided at a lower level of care. The CMS 2MN Rule was met.
What is Medical Necessity: CMS 2MN Rule
An outpatient claim that is partially denied for no authorization. Not all treatment days being listed on a valid and approved authorization.
What is Authorization: Partial Authorization Obtained
For Bolingbrook facility, what should the title of the first letter sent to Devoted Health Medicare be?
What is Appeal
When a POC/PD payer denies ICU vs PCU vs Med Surg/NICU/LTAC charges stating that inpatient care could have been safely provided at a lower acuity level, for example ICU vs Med Surg charges (this is not the same as patient class "IP vs OBS" denial) MCG/IQ Criteria was not met
What is Utilization Management
249
What is a readmission?
A claim denied for medical necessity. There is proof of a valid and approved authorization for a simple surgery. The operation note indicated the simple surgery was changed due to the discovery of extensive disease.
What is Authorization: Intra-Procedure change or added procedure
A claim is denied by BCBS for no authorization. There is proof of a valid and approved authorization with Humana. BCBS was not identified as the payer until after the date of service.
What is Authorization: No admission notification
For Ottawa facility, what should the title of the first letter sent to Aetna Medicare be?
What is Reconsideration