Enter Title

Variations

100

If a person is treated for back pain in the lookback of a pre-existing claim with a California Situs, what do you need to know to determine if it is pre-existing? 

Was it a diagnosed condition. 

200

In New York, it is not permitted to deny benefits for a pre-existing condition.  What do New York plans do instead?

The New York plans will limit benefits for a specific period due to a pre-existing condition. 

300

What else is different from the typical ML plan pre-existing condition clause in California Variations?

the exclusion of reasonable prudent person wording. 

and the three-pronged provision is not permitted

400

what other types of plan funding are there other than fully insured

Self-funded (administrative services agreement)

limited funding (when the funding arrangements for a claim change from fully insured to self-funded) 

500

In New York, when is it allowed to deny a claim for a pre-existing condition? 

If the plan is self-funded.

Pre-ex Overview

100

The pre-ex-investigation manages what for the company?

risk 

200

What is the first thing you need after the interview to start your pre-ex-investigation?

Medical authorization 

300

Name three things that should be on the pre-existing review templet 

any three: 

pre-x info (doh, ied, dlw, ddc)

pre-x provision

disabling conditions 

pharmacy profiles

calls to providers and medical requested 

conditions confirmed pre-extisting 

outcome of review 

400

After all information is received, what steps are taken to complete your pre-ex-review?

review the medical records/pharmacy records 

and if unclear request NC/PCS assistance

500

When making a call to a medical provider's office, what information should you ask for? 

You are looking to see if there was treatment in the Look back period. 

Accident or Incident

100

If pre-ex is ruled out due to verification of the disability from a specific accident or incident, what information is required in the approval letter?  

Notice of the ongoing pre-x investigation. 

200

What are some examples of an accident or incident and diagnosis that may allow a pre-ex-investigation to be ruled out for a condition? 

anything reasonable, stroke, heart attack, fracture after mva

300

Do you continue the pre-ex-investigation if you have already approved the claim after ruling out the primary disabling condition is not pre-existing? 

yes 

400

What do you do after the pre-existing review is complete on a claim approved after the primary disabling condition was ruled out due to it resulting from a specific accident or incident? 

You would advise the claimant of the outcome of the investigation

500

Why is a back injury not necessarily a good disabling condition to rule out a pre-existing condition from a specific accident or incident?

The claimant may have an underlying back condition that was exacerbated by the accident/incident.

Best practices

100

Why it is important to document the pre-x review outcome in the action plan? 

This is helpful for anyone reviewing the claim to know what pre-existing conditions were found.

200

Can you refer a pre-existing review to clinical along with a request to assist with determining if restrictions and limitations are supported?

yes, with a detailed referral specifying both needs.

300

In a pre-existing review who do we request medical records from?

We request medical records from all providers the claimant treated with in the lookback.  

400

Describe a best practice for handling a pre-existing investigation.

any