FWAE (why are you the FWAE you are)
True or False:
The codes "OA" and "4A" are classified as hard codes?
True
What part of the Member Appeals SOP steps have to be completed in order to place your questions on the SME sharepoint, unless the questions is about those fields?
Refer to Completing ETS Fields and ETS Case Entry for additional information on which fields the RA must check, and how to verify their accuracy.
In the Member Appeals SOP, which process is conducted first: verifying the timeliness of the appeal or the authorization representative process?
Timely Filing
Which redirects require SME approval?
Member Authorization requests and Executive/DOI Complaint (PW/LT remark codes )
True/False: Below is the appropriate letter language to address why a claim did not process under Preventive Care.
Determine Benefits
We make administrative decisions regarding whether the Policy will pay for any portion of the cost of a health care service you intend to receive or have received. Our decisions are for payment purposes only. We do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions.
We have the final authority to do the following:
• Interpret Benefits and the other terms, limitations and exclusions set out in this Certificate, the Schedule of Benefits and any Amendments.
• Make factual determinations relating to Benefits.
We may assign this authority to other persons or entities that may provide administrative services for the Policy, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time as we determine. In order to receive Benefits, you must cooperate with those service providers.
False
The correct language is:
In your letter, you stated that you received preventative service(s). Please note that the codes submitted by your provider were not for preventative service(s).
This issue is classified as FWAE and is not managed by E&I Appeals. List at least two ✌ remark code that will be redirected:
7Y, FO (F alpha), FT, G1 (G numeric), HX, FJ, HW
What SOP gives you the adjustment macro and what is the macro?
Requesting an Adjustment SOP – Step 6, The Adjustment Request for ETS macro (Ctrl + Alt + A)
In the Authorized Representative SOP, what systems are we instructed to check to determine if there is an authorization on file for UNET cases?
Doc360, ORS, ETS, UNET FCI screen
Name 3 of the 8 situations where the Reassign SharePoint should not be used for a reassign request.
Case due same day; Case out of compliance; Urgent case; Case is due over the weekend/holiday and it's past 4 pm CST Friday; Case needs to go to a specific RA; RA handled a previous level review in another case; External appeals; PCA needs to be reassigned to a different area or RA.
True or False: When sending a Member Authorization request letter we send the letter to the Member and cc the provider.
False.
Submitter provider and cc the Member
If your claim processing history shows denials with codes OT, OX, or 47, what should you do next?
Go to the OrthoNet Process section.
What is the Macro referenced in the Member Appeal Resolution Process - Clinical Research section that is used for clinical referral comments?
Clinical Comment Macro (Alt + M)
True or False: We can handle these non-appealable outcomes as duplicates?
Redirects, Appeals Rights Exhausted, Closed for Member Auth, Withdrawn, Surprise Medical Billing (No Surprises Act - NSA), Responded to Inquiry
False
True or False - In order to save compliance, it's appropriate to close a case and create a PCA when the case is still with/pending a response from a business partner?
False, unless the business partner returns the case advising us to close with a PCA
True or False: It is appropriate to use the word "unproven" in NY medical necessity cases if provided in the FMD letter language response?
False
NY medical necessity cases: The word unproven
NY notes:
True or False:
The remark code "HR" indicates that the claim was denied.
False
Per the Authorized Representative Process SOP, if the authorization was not submitted on the UHC Designation of Authorized Representative Form, what tool would be used to see if the submitted AOR is valid?
Access the Designation of Authorized Representative Decision Tree.
If there is a duplicate case how many days must we allow the appellant to receive the most recent determination?
15
The SALR shows 2 levels of appeal, and the COC shows 1 level of appeal. Which would you follow?
SALR tool as we will always offer the most stringent of the 2
This job aide is to be used to report when we find we have responded to a third party without member authorization and have violated the member’s privacy.
What is the Privacy Issue – Job Aid
Please list one of the OptumInsight Task Reviews that are considered as completed task by OptumInsight:
Perform Case Review (Clinical)
Perform Subsequent Review
Perform Appeal Review (Clinical)
The task Perform Case Review (Non-Clinical) reflects Optum's Initial Review ONLY for claims with A7 denials.
For the Fully Insured policies, which two SOGs provide first level as Hearing?
SOG WI, DC (except for FEHB - Federal Employee Health Benefit)
Where can you find state law?
State specific Appeal process initial Review Section (Member appeal SOP) and SALR tool.
Where on a HCFA 1500 claim form would you find the corrected claim indicator?
Bonus Question: What is the corrected claim indicator?
Box 12 A
Bonus Answer - 7
List at least one of the four reasons a corrected letter would need to be sent:
Incorrect provider information in header or body.
Note: If a provider's name is misspelled, a corrected letter not needed.
Incorrect payment/processing information.
Example: If a letter says we paid at 100%, but it really applied to deductible.
Incorrect FMD in determination letter.
Incorrect member/patient listed in the letter or letter sent to the incorrect address.
Notes:
This may also be a privacy issue that should be reported to the privacy office.
If it has been verified, letter needs to be sent as directed to a specific address in the appeal.
The benefit language was incorrect:
Incorrect outcome (decision).
Incorrect/missing plan/policy language: if correct language is included but more than what was needed, no updated letter.
Information from medical review has changed:
Missing/Incorrect FMD language.
Note: Correction would be necessary unless the wording provided in the original response is materially the same but worded differently. Same decision.
Incorrect approval information (dates/units/authorization number) for authorization on pre-service cases.
Incorrect member rights were sent:
Missing/incorrectly given ERISA rights.
Appeal rights missing/incorrect.
FI - Wrong State template for the Resolution Letters: This would result in incorrect rights being issued on letter. This should be corrected every time.
FI - Wrong State template for the Acknowledgment Letter: As long as we identify prior to a resolution letter being sent, send a new letter. If we have already sent the correct resolution letter, do not send new Ack letter.