Appeal Basics
This type of appeal is submitted before services are rendered.
What is a pre‑service appeal?
Standard pre‑service appeal decisions are typically made within this many days.
What is 30 days? (May vary by plan)
This document explains why the service was denied.
What is a denial letter?
The most common reason for pre‑service denial.
What is lack of medical necessity?
This person may initiate a pre‑service appeal.
Who is the member or provider?
This appeal challenges a medical necessity or authorization denial.
What is a medical appeal?
Expedited appeals often require decisions within this timeframe.
What is 72 hours?
Clinical records used to support medical necessity.
What are medical records?
Criteria such as MCG or InterQual are used for this purpose.
What is determining medical necessity?
This role often conducts the clinical review.
Who is a medical director or nurse reviewer?
The first level of review, often conducted internally by the health plan.
What is a Level 1 appeal?
The clock starts for appeal review once this is received.
What is a complete appeal request?
A provider’s written explanation supporting approval.
What is a letter of medical necessity?
This occurs when requested services are not covered by the plan.
What is a benefit/exclusion denial?
This multi‑disciplinary process ensures fairness.
What is the appeals review process?
This appeal is initiated by a provider or member prior to care.
What is a pre‑service appeal?
Failure to meet appeal deadlines can result in this.
What is an automatic overturn or compliance issue?
Missing documentation can cause this appeal outcome.
What is an unfavorable decision or dismissal?
Appeals reviewers must consider this updated information.
What is new or additional clinical data?
Members have the right to submit appeals in this manner.
What is verbally or in writing?
An appeal requesting immediate review due to risk of serious harm.
What is an expedited (urgent) appeal?
*DAILY DOUBLE!*
Regulatory timeframes are most often governed by these entities.
What are CMS, state regulations, or the plan document?
The member’s written permission allowing a provider to appeal on their behalf.
What is an Authorization to Appeal (AOR)?
Appeals cannot approve a service that violates this.
What is the member’s benefit plan?
Language services or accommodations fall under this right.
What are member rights and protections?