Variations
When can MetLife deny a claim for Pre-existing conditions in New York?
A: when the funding is not fully insured
The pre-ex-investigation manages what for the company?
risk
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-ex investigation.
Why it is important to document the pre-ex review outcome in the action plan?
This is helpful for anyone reviewing the claim to know what pre-existing conditions were found.
California variations require an additional piece to the pre-existing investigation. What is this piece?
A: the claimant received medical treatment, care or services or took prescribed medication during the “look back period”, it must have been for the same diagnosed condition as the Disability.
What is the first thing you need after the interview to start your pre-ex-investigation?
Medical authorization
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
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.
What is another of the two differences in a California Variations pre-existing investigation?
A: either :
1. the exclusion of the “reasonably prudent person” wording
2. three-prong (i.e., 3/3/12) provision is no longer permitted
Name three things that should be on the pre-existing review template.
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
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
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 that treatment has not been ruled out for in a phone call and medical records needed for the current disability period.
Other than fully insured what is another funding type?
self-funded or administrative services agreement
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
If you determine that pre-existing condition can be ruled out because a medical condition is accident related and you have later completed the full investigation, what is your next step?
You would advise the claimant of the outcome of the investigation
Describe a best practice for handling a pre-existing investigation.
any
In New York, if a claim is pre-existing what do you do?
MetLife will administer this provision as a limitation of no benefits payable during the pre-ex limitation period listed in the provision,
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.
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
If you do not have an authorization, when do you start your investigation?