It's Denied
Places to locate a payer correspondence.
What is OnBase, Epic Referral, or RamP8 (older accts)?
HCPCS Code for Leuprolide acetate (Depot Suspension).
What is J9217?
This is the process of getting approval before a specific service or medication is provided to ensure it is medically necessary.
What is Prior Authorization?
This marker is used specifically to determine if a breast cancer patient will respond to the drug Herceptin.
What is HER2 (or HER2/neu)?
This imaging modality uses powerful magnets and radio waves to create detailed "slices" of the body without using radiation.
What is an MRI?
This specific type of review allows a physician to discuss a denied authorization request with a payer's Medical Director before a formal appeal is filed.
What is a Peer-to-Peer review?
HCPCS Code for Pegfilgrastim (Neulasta).
What is J2506?
Insurers often deny types of treatments, claiming they are still in the testing phase and not yet "proven" for general use.
What are Experimental or Investigational treatments?
This maker is the primary tool for monitoring pancreatic adenocarcinoma.
What is CA 19-9?
A blood glucose level is drawn before obtaining this imagery.
What is an FDG PET/CT scan?
This type of request/form is usually sent prior to beginning the formal appeal process.
HCPCS Code for Romiplostim (Nplate).
What is J2802?
In most cases, if a provider fails to obtain required prior authorization before performing a non-emergent surgery, this is the typical administrative result for the claim.
What is a Denial?
Clinical indicators to obtain GI Pathogen testing (CPT 87507) for an immunocompromised status.
What is acute or persistent diarrhea, fever, severe abdominal pain, bloody stools, and/or dehydration?
This is considered the only definitive way to confirm a cancer diagnosis by examining a tissue sample under a microscope.
What is a biopsy?
Hospitals face denials if documentation fails to prove the patient's clinical need for a stay spanning 48 hours.
What is the Two-Midnight Rule?
DOUBLE JEOPARDY: This drug, used to treat certain leukemias and lymphomas, was originally discovered in the bark of the Pacific Yew tree.
What is paclitaxel (Taxol)?
Members generally have this many days to appeal a denied claim.
What is 180 days?
Tumor markers are not just used for diagnosis, they are vital for checking for this- the return of cancer after treatment.
What is recurrence?
This type of scan uses a radioactive tracer to identify areas of high metabolic activity, which can indicate cancer.
What is a PET scan?
In 2019, a judge famously criticized this insurance giant for "immoral and barbaric" denials regarding proton beam therapy for prostate cancer.
Who is UnitedHealthcare?
This common side effect is a sore, inflamed mouth or throat, frequently seen in patients taking methotrexate.
What is mucositis (or stomatitis)?
The primary online portal where providers can submit clinical information, check eligibility, and manage prior authorization requests.
What is Availity?
DOUBLE JEOPARDY: Often associated with ovarian cancer, this marker is also used to monitor treatment response and recurrence.
What is CA-125?
A "Grade IV" histologic classification on a pathology report indicates that the tumor cells are this- meaning they look very different from normal cells.
What is undifferentiated (or highly malignant)?