Required attachments.
This should be attached to every case.
The EOC or claim image.
The claim pays in CAS after appeal was received, and no instructions was sent to CRU to reprocess the claim. What should the appropriate status reason be?
Previously Resolved.
If the case is submitted by Availity and the address was not specified in the appeal and the address type is billing. Which address should be notated in the case notes section?
The Billing Address.
This should be added to all dental cases.
Hint: Specifically for dental cases only.
Dental slick/ EOC showing dental benefits.
If the case is approved based on the benefit in the EOC or contact scenarios. What should the status reason be?
Contractual Overturn
Scenario- This is a member's appeal and the address on the envelope/online submission is different from the address on the blue banner. What should be done by the associate?
A call should be made to the to verify which address should be used.
The case is an upheld case and the LOB is a dual SNP. What should be added to the attachment section.
A MARx image.
If the case is overturned due to an authorization being on file and this auth was on file before the service were rendered. What is the correct status reason?
Claim Processing Error.
Which 2 appeal submitters are exempted from using the appeal hierarchy when determine the address?
Hint: There address would be found in the Government Programs Addressing the Letter document.
Zotec Partners/Revenue Recovery Center or Wound Management Specialists.
The case is an approved dental case and a screenshot of this should be attached to the documents section.
Hint: This is specific to approved dental cases.
MTV showing the proof of effectuation.
The claim rejects for 08Z and the referring provider is par and the services rendered were urgent. What should the correct status reason be?
For appeal cases where the representative is submitting on behalf of the member, list 3 places in which the address can be found.
The AOR form, the appeal letter, the envelope or the OGO notes in CRM attachment.
For 18W cases this letter is needed in order to process the case.
CMS certification letter.
If the case is an auth & referral and a provider can't be found within the specified distance what should the status reason be?
No contracted Provider Available.
List the address hierarchy in order, for cases where the provider is the submitter, and the address isn't specified or one of the submitters that are exempted from the hierarchy.
Address within the appeal. (G&A form, Appeal letter, signature line)
Return Address on envelope.
Adress on the letterhead of the appeal.
Claim form/corrected claim included with appeal.
Claim image.