Back to Basics
This insurance is for people 65 or older. You may be able to get itearlier if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also called Lou Gehrig’s disease).
What is Medicare eligibility?
This CI Screen shows the current and former PCP of a given member.
What is the PAMG screen?
What plan type requires authorizations prior to services being rendered?
What is HMO?
This document is not required to be submitted with the case file if the appellant works for the doctor
When submitting a Dismissal in the portal, this is the Issue Category/Item Service Category used.
What is Appellant Dismissal Case File?
This part is known as hospital insurance and does not carry a premium.
What is Medicare Part A?
This CAS screen houses SIU, Hospice and certain claim processing information
What is the CWI Screen?
A WOL form is not required for appeals filed by these entities.
What is Department of Defense (DOD), Veteran's Affairs (VA), or Indian Health Services (IHS)?
This case priority gives IRT 24 hours from the MD decision OR 24 hours from the case due date (whichever comes first) to submit the appeal to the IRE.
What is an expedited appeal?
These are 3 examples of a dismissed appeal.
What is timely filing, AOR/POA not received, WOL not received?
This part is also known as your Medical Insurance
What is Part B?
This CI screen houses the plan type, and full contract number/PBP
What is the IPBD Screen?
This process should be used when a member or AOR is appealing for reimbursement of services already received.
What is Direct Member Reimbursement?
What is an AOR?
In this section of the ExRM UI, you see the original case#, original appeal type, original case status reason and requester information.
What is Intake?
This type of Medicare coverage is purchased as a package with MA coverage and PDP coverage (MAPD) through a private insurance.
What is Part C?
This CAS screen is used for displaying accumulation history information for a member or plan for a particular month in a year.
What is the MAI Screen?
This EOC should be submitted when an appeal is received in 2024 for a 2023 DOS.
What is the 2023 EOC?
This type of appeal is chosen when a representative of the member calls with a verbal appeal and the member grants permission to speak with the representative on the phone.
What is a member appeal?
This is when the appellant disagrees with a dismissed appeal.
What is a vacate dismissal request?
If a member has Traditional Medicare, but wants extra coverage for the 20% not covered.
What is a Medicare Supplement (Med Supp) plan?
This modifier in CAS indicates the allowable per unit
What is the U modifier?
This date is used as the Humana Received Date for the new appeal when Humana has vacated a previous dismissal.
This is required to be completed/sent by the 72-hour mark when a case priority is changed from Expedited to Standard Pre-Service.
What is the Expedited Appeal Criteria Not Met letter?
These are 2 examples of why the IRE may overturn a dismissal.
The appellant has shown good cause
The MHP did not provide proof of diligent efforts when requesting AOR/POA/WOL