Time Frames
First level grievance reviews must be requested in writing on the Request for Appeal or Grievance Review form within _____ of a denial for coverage.
180 days
Where is a member Appeal form submitted to?
PO Box 30055 • Durham, NC 27702-3055
What is the Category & Sub Category for member appeals?
Grievance > Member Appeals
What two types of a Provider Courtesy Review (PCR) do we handle?
Prior Authorization & Quantity Limitation Denials
Members of the State Health plan can receive assistance with grievances from The Health Insurance Smart NC by contacting:
North Carolina Department of Insurance
For a level One Appeal you will be notified in written terms of the decision no later than _____ from the date the State Health Plan or its representative received the request.
30 days
Appeals Require what information?
Member/dependent #, Document Control Number #, DOS, Claim #, Provider #, explanation of problem.
______ is when the FDA has decided the benefits of the approved item outweigh the potential risks for the item's planned use.
FDA Approvals
Scenarios and process if which case?
1. The fictitious name of Bernard F. Null will be used in communications to the member in order to protect Blue Cross NC staff.
2. A unique telephone number will included in communications to the member directing the member to a telephone located on the Supervisor's desk.
3. All calls will automatically be forwarded to voicemail, which will be checked daily.
4. Calls will be returned by the analyst handling the case.
In the event an appeal is received from someone who may be perceived as a potential threat (determined by review of the patient's history and presence of a psychiatric and/or substance abuse diagnosis)
If you are dissatisfied with the first level grievance review decision, you have the right to a second level grievance review. This request must be made in writing within ______ of the first level grievance review decision.
180 days
What is the North Carolina Department of Insurance address:
Health Insurance Smart NC, 1201 Mail Service Center, Raleigh, NC 27699-1201
Non DIM pre-service reviews from providers should go through _____ first? If services are denied then the member has the right to appeal.
UM / MHPO
_______ provides guidelines for determining coverage criteria for specific medical and behavioral health technologies, including procedures, equipment, and services.
Medical Necessity per Medical Policy
An appeal of a non certification that may be initiated by the member, Provider, or the Member's designated representative when a non expedited appeal would reasonably appear to seriously jeopardize the life or health of a covered person or jeopardize the covered person's ability to regain maximum function.
Expedited Appeal
The second level appeal review which will be conducted by a review panel coordinated by the State Health Plan, will be held within ______ after the State Health Plan or its representative receives a second level grievance review request.
45 days
State Health Plan Appeals Fax #?
919-765-2322
If the Activity status is ________ with a resolution code ________, do NOT respond in the Notes field.
Instead, open a new activity with all related information, include the response, and close the original request.
Delivered / More Information Required
_________ is a vendor that denies a claim based upon their maintained library of claim edits customized for Blue Cross NC.
I Health Denials
After a level 2 Appeal a written decision will be issued to you within ______ of the review meeting.
5 business days
An expedited review may be initiated by calling the State Health Plan Customer Services number. The decision will be communicated by phone to you and your provider no later than ____ after receiving the request. A written decision will be communicated within 4 days after receiving the request for the expedited review.
72 hours
What does a Provider need to submit an appeal on the members behalf?
Level One Appeal form & Members Authorization / Signature
There is a ________ time for PCR cases. Review the Appeals Analyst name on the Medical Management tab in Service First for valid SHP PCRs.
7 day turn-around
T/F - A member cannot file an appeal for anesthesia modifier related denials?
False
Where can you view member submitted claims?
In Care Radius, or Service 1st: Member screen, Appeals sub tab