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MYTHBUSTER: Does the ALJ system work?
December 6, 2022 8:31 amMYTH: The ALJ System doesn’t work. FACT: The ALJ System DOES work. In a case study, a patient was referred to the... View more
The Case of Phenylketonuria
November 8, 2022 8:30 amIn a recent case study, a patient was diagnosed since birth with Phenylketonuria (PKU) a rare genetic condition, an inherited... View more
Have You Been Haunted By Medical Necessity Denials?
October 25, 2022 8:31 amOne of the biggest pains we face is medical necessity denials. Despite sending proper notifications and requesting authorization on time,... View more
MYTHBUSTER: Who has the authority to establish medical necessity?
September 1, 2022 8:00 amMyth: Any physician is allowed to determine if medical criteria was met to establish medical necessity. Fact: A physician or appropriate... View more
Obtaining Authorization While Patient Is In House
June 29, 2022 8:44 amA large 11 hospital provider member recently submitted a complaint to ERN/TRAF against a health plan who failed to approve... View more
MYTHBUSTER: Are MA plans required to respond to inpatient authorization requests?
June 27, 2022 1:20 pmMYTH: MA Plans are not required to respond to an inpatient authorization request. FACT: MA Plans ARE required to respond to an inpatient authorization... View more