Misc
T/F: The Root Cause in your EIQ note should match the EIQ Appeal Reason.
True
T/F: When appropriate to the denial, Appeal Nurses should change the Appeal Reason in EIQ from Readmission - Related Readmission that was preselected by IR/Triage?
True
T/F: All denials under CARC Code 50 are appropriate to assign the RC Med Nec-Lacks Doc to Support Med Nec?
False
T/F: No Auth Obtained-No Evidence Auth Verified and P2P Performed-Denied NMN should be used interchangeably.
False
Auth still shows pending on payor's website stating no clinical received, which would be the correct RC in EIQ?
No Clinical Submitted-Clinical Not Received by Payor
Readmission denial: Patient was NON-compliant with primary care MD appointments but compliant with medicine regimen. What is the best EIQ root cause?
Readmission - Patient Non-Compliant
Payor denied payment for patient receiving bone graft substitute during procedure: What would be best RC choice in EIQ?
Experimental Procedure - Experimental per payor policy
Denial Code 197: Auth was approved for OP testing, patient converted to IP, which would be the correct RC in EIQ?
Denied Days - Auth precerted obtained for OP
What is the best root cause for an authorization denial where the patient's coverage changed after discharge?
No Authorization Obtained - Incorrect Payor at time of Service
Readmission denial, however 2nd admit was unavoidable even with BEST discharge plan in place: What is the best RC choice in EIQ?
Readmission - Related Readmission
Vitamin D blood level outpatient testing denied under code 55: Which would be the best RC in EIQ choice?
Experimental Procedure - Experimental per payor policy
Denials received under CARC Code 50 are generally what type of denial?
Level of Care
CM sent auth request via fax but fax failed & was not resent for 3 days. Payor denied w/197, what is best RC in EIQ?
Missed Notification-Notification Missed Untimely
Denied full payment stating readmission: Index admit was CHF; 2nd admit patient slipped & broke hip. What is best RC choice?
Readmission - Unrelated to Previous Admit
Patient admitted for appendectomy & MD also removed normal gallbladder: What is best Root Cause choice in EIQ?
Add-On Procedure - Did Not Meet Medical Necessity Policy
Denial Code 50 received with p2p completed and upheld: what is the best root cause choice in EIQ?
P2P Performed denied NMN