Decision Tree
For Part C, which of the following can be done verbally?
A. Standard Pre-service Appeal
B. Standard Post-Service Appeal
C. Expedited Appeal
D. All of the above
Expedited Appeal
Who can file a Coverage Determination?
A. The prescribing physician
B. The prescribing physician
C. The pharmacist
D. A and B only
The prescribing physician,The prescribing physician.
Mr. Smiley calls in today indicating when he was out of town a few weeks ago, he had to seek medical care. He did not have his ID card with him so he paid out of pocket for the visit. Mr. Smiley wants to be reimbursed for what he paid out-of-pocket. How would you categorize this call?
A. An Appeal
B. A grievance
C. An expedited appeal
D. An organization determination
An organization determination
A. Educate Mr. Immen on coverage for cosmetic procedures and precertification is needed. Ask the member if his doctor will be submitting the request for prior approval or offer to warm transfer him to the Pre-cert department for an organization determination.
B. Educate Mr. Immen on the standard medical procedures covered under Medicare Advantage plans and explain cosmetic procedures are not covered.
C. Explain to Mr. Immen this procedure is considered to be a cosmetic procedure and this will not be covered. If he gets upset, offer to file a grievance on his behalf.
D. Explain to Mr. Immen this procedure is considered to be a cosmetic procedure and this will not be covered. Advise the member he can submit for an appeal to get this covered.
A Educate Mr. Immen on coverage for cosmetic procedures and precertification is needed. Ask the member if his doctor will be submitting the request for prior approval or offer to warm transfer him to the Pre-cert department for an organization determination.
Members have the right to request an expedited appeal if they believe the ___________ standard reconsideration process could jeopardize their health, life or ability to regain maximum function.
72 hours