Dismissals/Vacates/Exhausted Rights
If we receive a new appeal that we upheld and Federal Maximus upheld, the status and status reason we would use for our newest inquiry would be?
What is exhausted rights
Once a valid aor is received, it is valid for
What is 1 year from date both parties signed
Once we have verbally confirmed member is no longer inpatient and date of discharge, we transfer to _________ tank
Who is Jason Kallio
On RMD form if appeal is for home health what do you include in the # of days used and # of days eligible
What is Home Health and Home Health
When updating CGX and adding the new notification, we should use the following date do we use for the new notification date
What is Enter the date the appeal was received in the New Notification Date
What is 65 days
What POA type do we have to send to legal to confirm if it is valid for appeals if it is already on file?
What is type O
Which appellant type do we not need to make an acknowledgement call to?
What is contracted provider
Is subcategory is LTACH and we have 4 hours for the nurse to review, what subtask will we use?
What is MA MD Review Facility/Personalized Care subtask
If you have a California IPA due over the weekend and you have not received a response from IPA before end of day Friday and its been overturned, what are our next steps?
What is send escalation and effectuate CGX
These 2 provider types are required on provider tab in MHK for dismissals
What is treating provider and provider
If member's spouse who is also a Physician files an appeal on members behalf, our requestor should be set up as ______.
What is contracted provider
If we are unable to reach aor/member/poa successfully for acknowledgement call, how do we need to handle the appeal and by what time frame?
What is send case for a same day review by hour 24.
Per RMD form job aid, if you have a previous authorization on file that is approved in last year, the following are required fields
What is authorization #, ICD codes, CPT/HCPcs/service codes
If effectuating an inpatient surgery authorization, we should extend the authorization for the following amount of days
What is 90 days from the MD decision
If an AOR is appealing and we have approval to dismiss for timely filing, our status and status reason should be
What is untimely appeal submission - member
If a letter is written in third person, and both the member and appellant sign, our requestor section should be set up as _________.
What is member appeal
_________ should be attached to case if the appeal was filed before the NDMC
What is screenshot of the verbal appeal rights
For scheduling purposes of our clinical subtasks (either to MD or nurse), our business hours that we should set subtasks between ____________
What is 08:00-5:30 pm (est)
If updating an end date would shorten the date span on the current authorization for an outpatient authorization for 90 days, what do we do?
What is do not adjust the end date
Per the government programs letter matrix, the following dismissals require manual letters
What is Previously Processed scenarios when the appellant is not authorized and No Jurisdiction - Fast Track Appeal Rights (QIO)
If a Nurse Practitioner is appealing and is also the treating/ordering provider, our requestor should be set up as _______.
What is AOR
For IRE remands, how should we validate the received date?
What is date should reflect the date on the IRE fax coversheet.
If discovered that a MD/Nurse review subtask was created in error, we should do the following
What is notify tl/fll
When effectuating an inpatient behavioral health authorization, how long should we extend authorization or what should we do if the MD does not specify approval range?
What is Reach out to MD for guidance