Appeals
What does the acronym CRD Stand for?
What is Cooperate received Date
Which Consent forms are required if a member files an appeal?
What is None
SFH’s request types are to be identified as what?
What is Complaint or Grievance?
Members/Participants have 90 days to file a grievance
What is False
What is Essential to meeting production?
What is time management ?
If I am downgraded what am I? & If No LOMN is received for me what letter should be sent to the member?
What is expedited & a No provider Cert letter
What is the difference between A Personal Representative & someone who is Authorized to share Info with filing an Appeal?
What is A personal Rep Is a Legal representative such as POA or Guardian & can act on behalf or the member while the other can not
If a member files a SFH's through the Plan what education provided?
What is file via OLTL/State
Pharmacy cases are assigned to whom
What is a nurse?
I am on Day 3 of the appeal receipt
What is a "Must Go" ?
What letter is sent to the member and includes ERO & SFH instructions?
What is an OUTCOME/DECISION LETTER
I am a member who the line with my daughter who is initiating my appeal?
What is the member?
I am an external complaint what address am I sent to ?
What is Pennsylvania Insurance Department Bureau of Consumer Services Room1209, Strawberry Square Harrisburg, Pennsylvania 17120
A _____ is filed when the member is denied a benefit Based on Medical necessity?
What is a grievance?
I should be Processed within an Hour of receipt
What is an expedited?
Name 3 Components of an Episode that should never be left blank when closed or Open?
What is Appeal for Box, Service line Decision, Assessments
I am a Shift care appeal do I require consent?
What is reach out to leadership?
What is the definition of an External Review?.
What is When a member does not like the decision Keystone First has made about a Grievance the member has filed, the member can ask for an External Grievance. An External Grievance is a review by a doctor who does not work for Keystone First
For what Service/s type are activities sent to an external department?
What is PAS, Home MODS, Shift care, Pharmacy
I was sent to Intake Late.. What am I?
What is a stale dated request?
When building an episode what are the steps to attach an episode to your case?
What is Select Yes for Attach Existing Episode? Click Attach, Click on the parent episode check all applicable lines, Click add too list, then View & attach.
I am a provider who sent in a Grievance for signed by my Patient.. Who is the appellant type?"
What is Provider on behalf of member
When Requesting a FH in writing what must the member include?
What is The member’s name date of birth, telephone number, Whether the member wants the Fair Hearing in person or by telephone. The reason for the request for a FH. A copy of any letter the member received
Name the most common Services assigned to a GC?
What is Dental, Radiology, PAS
Who should be included on emails to the Backend teams
What is the ENTIRE Company :) J/k
Leadership for that LOB
What is No signature Not completed in its entirety Missing pages
I am an Alt Payee of a member that is 21 yrs old, what should be documented in the SF of my request?
What is Verbal approval obtained from the member for the caller to file on their behalf.
What Information is included in a ERO request via Service form?
What is - Caller's name
Telephone number where caller can be reached
Grievance Coordinator's name
Original Grievance SF number
Which appeal type does not require a provider to be attached to the case?
What is PAS & FORMAL COMPLAINTS
I am Left Overnight & shouldn't be.. What am I
What is a Pended SF?
For PAS Denials, we should follow up before what?
What is Ack ltr OOC
I am usually on a Grievance/Complaint form and can not be questioned?
What is a Signature
What happens after a Fair Hearing ?
what is, it will be reviewed by DHS and a decision render in 90 CD.
What is the IP/Hospital Stay process?
What is
What is TOP Priority in Intake
What is Compliance?