42 CFR §422.566(d)
September 3, 2020 3:47 amIf the MA organization expects to issue a partially or fully adverse medical necessity (or any substantively equivalent term used... View more
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California Department of Health Care Services
August 28, 2020 4:44 pmWithin the California Department of Health Care Services, the Medi-Cal Managed Care and Mental Health Office of the Ombudsman helps... View more
VHA Script – Retroactive Denial for Authorized Care
May 24, 2020 7:06 pmASK YOURSELF: What date was the claim initially billed? Is there an Authorization on file? Were the services rendered consistent... View more
VHA Script – Poststabilization Timeframe
May 24, 2020 7:06 pmASK YOURSELF: When was the patient stabilized in the emergency room or admitted as an inpatient? Was it during normal... View more
VHA Script – Notice Requirements for Adverse Determinations
May 24, 2020 7:03 pmASK YOURSELF: Who denied the claim? What is the professional’s license number with the State Medical Board? Were they a... View more
VHA Script – No Authorization for ER Services and Care
May 24, 2020 6:34 pmASK YOURSELF: What was the patient’s presenting symptoms or chief complaint in the emergency room? Did the VA pay for... View more
ERISA Script – Untimely Payment
May 24, 2020 6:20 pmASK YOURSELF: What date was the claim initially billed? Was there any written communication (request for information, denial, underpayment) from... View more
ERISA Script – Notice Requirements for Adverse Determinations
May 24, 2020 6:19 pmASK YOURSELF: Who denied the claim? Were they a licensed physician or a licensed health care professional who is competent... View more
ERISA Script – No Authorization for ER Services and Care
May 24, 2020 6:17 pmASK YOURSELF: What was the patient’s presenting symptoms or chief complaint in the emergency room? Did the plan pay for... View more
MA Script – Poststabilization Timeframe
May 24, 2020 6:06 pmASK YOURSELF: When was the patient stabilized in the emergency room or admitted as an inpatient? Was it during normal... View more