Case Set-Up & Notification
This is where we find member's language preference.
What is under "written language" in medhok?
What three outreach categories do we audit for?
What is AOR, waiver and medical records?
The provider specialty for the RMD form is found here.
What is the NPI website?
The two components of the final resolution documentation.
What are case decision and decision rationale?
The subtask that you see on a regular case that you would not see on an IPA case.
What is the QA subtask?
A claim is reprocessed after Humana receives an appeal but before Humana receives a valid waiver.
What is a paid complaint?
These are the five data universe fields we audit for.
What is Humana received date, AOR/Waiver received date, decision date, effectuation date, and notification date?
The location of the case due date that goes on the RMD form.
What is the consolidated due date in Medhok?
If the status and status reason advise OT - Par Provider, but the Final Resolution Notes and OT Rationale state MD OT for Medical Necessity this is an example of what error?
What is Conflicting Decision Documentation?
If a claim is reprocessed by the IPA, what needs to be attached to the case to verify the effectuation date?
What is the reprocessed EOB from the IPA?
Two examples of good cause.
What is was the postmark date is within the timeframe, member seriously ill, a death in immediate family, a catastrophic event, or an adverse determination was sent to the wrong address?
The manual received date might be different than the reported at date in this situation for a non par provider appeal.
What is when a returned waiver is received?
What three items need to be reviewed for audit question "Is the case due date/ time correct?"
What is the date to RMD, case due date and was an appeal letter included with the request?
If an associate has located a referral from the member's PCP to the provider on the claim in question in the member's contact history, the decision on the case would be this.
What is Admin Decision - Overturned for Par Direction?
What is required from the IPA in order to begin working an IPA case?
What is the original denial file?
How do we handle a par provider submitting an appeal with a waiver.
What is a provider correspondence misroute/ invalid appeal?
The decision date may not match the first RMD's response for an uphold in this situation.
What is when the second RMD review indicates overturn?
The resource used to determine which attachments need to go to the RMD for each denial.
What is the Government Programs Medical Records and Supporting Documentation Decision Tree?
A claim form is included in an appeal and the claim is not in CAS. The case should be handled this way.
What is the case would be split to go to front end?
An IPA can be described as this.
What is an Independent Physician Association (IPA) is a group of physicians who have formed a company to manage and deliver both the healthcare services and the payment of claims. Providers are contracted or affiliated with the IPA group, and include both primary care physicians and specialists?
These are the four levels in the address hierarchy process.
What is 1. Specified address in the letter 2. Return address on the envelope 3. Address on the letterhead of the actual appeal, not an invoice. 4. Claim form or corrected claim included with appeal?
The number of outreach attempts recommended by the Outreach decision tree for medical records before submitting to the RMD.
What is three?
Where do you get the information for the diagnosis and procedure codes section of the RMD form and what information should be listed?
What is the Macess image, claim summary section? And what are the ICD 10 diagnosis codes, all CPT and Revenue codes, modifiers, and descriptions?
The two resources that can be used to find which letter template to use and what fields should be filled out.
What are the Medhok Letter List and the Government Programs Letter Matrix?
These attachments are needed specifically for IPA cases.
What is the IPA denial file, any email correspondence with the IPA and the reprocessed IPA EOB when applicable.