Warm-Up / Basics)
This initial step in the appeals process allows a plan or provider to take a second look at a denied claim
What is a Reconsideration?
This common denial occurs when a provider performs a non-emergency procedure without getting pre-approval from the health plan first.
What is a Prior Authorization Denial?
This germline test screens blood or saliva samples to identify inherited genetic mutations that increase a patient’s lifetime risk for developing cancers like BRCA-related breast cancer or Lynch syndrome.
What is Empower?: Focuses on hereditary risk (germline DNA), not active tumor monitoring.
Born and raised in West Philadelphia, this main character was sent to live with his wealthy Aunt Vivian and Uncle Phil in California after getting into "one little fight.
Who is Will Smith?
This formal request asks an insurance plan to reverse an adverse benefit determination, such as a denial of coverage or medical necessity
What is a First-Level Appeal
This term describes a denial triggered because the service rendered is explicitly excluded under the member’s policy benefit package.
What is a Non-Covered Benefit Denial?
This 397-gene panel tests blood or saliva to discover underlying hereditary causes or risk factors for chronic kidney disease (CKD) and kidney failure.
What is Renasight?
Originally intended as a one-time guest character, this high-voiced, suspender-wearing neighbor became the breakout star of the show with his catchphrase, "Did I do that?"
Who is Steve Urkel?
When a first-level internal appeal is upheld (denied), a member or provider can file this step to have the decision re-evaluated, often by a different internal panel or expert
What is a Second-Level Appeal?
When a claim is denied because another insurance company should pay primary before the health plan covers it, it falls under this process.
What is Coordination of Benefits (COB)?
This non-invasive blood test measures donor-derived cell-free DNA (dd-cfDNA) to assess the risk of active organ rejection in kidney, heart, or lung transplant recipients.
What is Prospera?
Set in a Brooklyn brownstone, this sitcom starring Queen Latifah focused on four female friends and paved the template that inspired NBC's Friends.
What is Living Single?
This type of dispute is filed directly by or on behalf of the patient regarding their benefits, coverage, or care, rather than a financial dispute filed by a hospital or doctor.
What is a Member-Level Appeal?
This denial reason means the service was deemed unnecessary according to clinical guidelines, even if the treating physician prescribed it.
What is a Lack of Medical Necessity Denial?
This tumor-informed liquid biopsy blood test is custom-built for an individual patient to monitor circulating tumor DNA (ctDNA) and detect molecular residual disease (MRD) or cancer recurrence.
What is Signatera?
Played by Martin Lawrence, this Detroit radio personality famously yelled "WZZZZUP!" and constantly bickered with his girlfriend Gina’s best friend, Pam.
Who is Martin Payne?
Medicaid members who exhaust their plan's internal appeals can request this formal administrative hearing overseen by an independent state judge to dispute a denial of care.
What is a State Fair Hearing?
Unlike a rejection, this operational denial occurs when a provider submits a claim long after the service date, missing the plan’s hard contract deadline.
: What is a Timely Filing Denial?
This comprehensive genomic profiling (CGP) test analyzes solid tumor tissue to identify targetable somatic mutations, helping oncologists match patients with precision therapies or clinical trials.
What is Altera?
This spinoff of The Cosby Show followed students at the fictional Historically Black College Hillman College, starring Jasmine Guy as the southern belle Whitley Gilbert.
What is A Different World?