Case Investigation and Documentation
The escalated timeframe (cases aged 42 to 55 days) given for the S/Lab due date.
What is 5 business days?
Modifier used to check member responsibility is CAS.
What is L modifier?
Appeal must be filed within 60 days of the Date of Occurrence/Cheque date.
What is Timely filing?
A case note that should be added for every case sent to the MD.
What is "Reviewer updated decision" or "No revision needed"?
Letter template that should be used when there is no provider within the specified distance.
What is OT Claims-Network Deficiency?
Status reason that should be used if there is no provider within the specified distance on the PFP.
What is No Contracted Provider Available?
The standard timeframe (cases aged less than 25 days) given for the MD due date.
(Updated flow)
What is 10 business days?
The error category that should be captured if the body of the letter includes codes without a description.
What is Humana or insurance jargon (such as acronyms) used without explanation?
The 3 fields on the WOL form that has to be present for the case to be valid.
What is Member's Name, Provider Signature and Date(s) of Service.
A LOB or member's policy that should be automatically approved if it is an auth and referral rejection.
What is a Private Fee For Service (PFFS)/LOB 3G?
The error category that should be captured if the member's responsibility is missing for the CRU subtask.
What is Incorrect Co-Pay or Co-Insurance Amount?
Two auth and referral error codes and Providers that has a process deviation.
What is 44X and 02R, Tempus and Guardant Health?
A policy that can be overturned when a non-contract provider submitted the request and does not have an authorization on file.
What is a PPO policy?
Five error codes that have their own document in the Medical Case Research section.
What is 015, 653, 05D, 0G/, 18W?
A remand that cannot be dismissed for Timely Filing.
What is IRE remand?