2nd Level/Hearings
What must be done for Hearing Cases?
Backdate 5 business days from the plan due date, unless the hearing packet has a specific date.
Additional Information Received within 14 days: If no intent of 2nd level Appeal and/or FLN is additional information received within 14 days of the Appeal Determination.
Yes
If a Mandate applies you do not set up the case?
False
How would you write an appeal that does not have medical records?
ATS# 1st/2nd Appeal Request
What must you do for PG groups?
Make Escalated due date 5 business days prior to plan due date.
What is Level of Issue Type for a hearing case?
1st/2nd Level hearing
If Claim Remark Code is DR?
yes Denied for Lack of Referral: Return to Benefit Operations.
Do 2nd Level follow the Admin process?
No
How do you name conformation of an outreach?
ATS # 1st/2nd Fax Outreach Confirmation
Is a hospital a preferred site of service for eviCore?
NO
If you find a "duplicate" ATS/ETS case and the FLNs attached are different, your case would not be a duplicate. What would it be?
Additional Information
Duplicate Case but yours is marked urgent.
No
For CPT Codes: 15830,15832 – 15839, 15847,15876 – 15879 that Explicitly excludes removal of hanging skin, abdominoplasty, panniculectomy, thighplasty, brachioplasty or mastopexy.
What do you?
Return to Benefit Operations as out of scope with return comment: COC/SPD Plan Exclusion.
Is this written correctly for LCD policy?
Manual Wheelchair Bases, Local Coverage Determination (LCD) L33788, Effective January 01, 2020
Yes
What system do you use to to look up eligibility for Surest?
UHSS
If there is no request for second level what is the next step.
If there is no request for second level
Services Covered/Approved: Determine if all service codes were approved in HSR. If the request is showing all codes approved in HSR.
Yes return to benops
If Explicitly excludes Breast Reduction. What is your next step?
Review HSR case Notes, Appeal request, and any other case history to determine if the member has prior history of breast cancer treatment or mastectomy and the purpose for the request is to gain symmetry in a non-affected breast. 1. If no history of breast cancer treatment or mastectomy, return to Benefit Operations as out of scope with return comment: COC/SPD Plan Exclusion. 2. If history of breast cancer treatment or mastectomy or if the clinical indication for the breast reduction is in question, Assign to the Appeal Nurse for Clinical Review per standard workflow.
How do you name an policy PreFace 3.1, MS-24 and the guidelines that was reviewed on 5/5/2026.
Cardiovascular and Radiology Imaging Guidelines, Version 3.0.2026, Clinical Information Preface 3.1, General Guidelines MS 1.0, Hip MS-24, Effective May 4, 2026
If no, document within the case prep template (Case Comments) that validation was performed indicating the service is not on the Carrum Mandatory List. What do you do?
Proceed per standard workflow.
What are all the doc you need for a 2nd level appeal?
- pre 1st denial file (first level appeal)
- pre 1st resolution letter
- initial denial file
- initial denial letter
- 2nd Appeal Request with Medical Records
- 2nd SPD/COC
- 2nd Medical Policy
Member Termed: Verify member eligibility in ISET/Cirrus Benefits plan tab (5)/ACET/HSR. If an effective policy for the member is found, and the group number, group name, set number/Bundle option ID, plan type and Alt ID are all the same.
No proceed with review
Morbid Obesity Surgery CPT Codes: 43644, 43655, 43842, 43843, 43846, 43847, 64681. Does not explicitly exclude morbid obesity surgery, or if specific criteria for coverage is provided in the Covered Services section. What is your next step?
Assign to the Appeal Nurse for Clinical Review per standard workflow.
How do you name an Oxford policy SP-2.3 that was reviewed on 6/8/2026.
Oxford Cardiovascular and Radiology Imaging Guidelines Version 4.0.2026 , CT of the Spine SP-2.3, Effective June 4,2026
If there is no SPC/COC what do you do?
Use the BTB and E&I Benefit Template.