Medicare Managed Care Manual, Chapter 4, § 10.16
May 23, 2020 4:08 pm“…if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage... View more
Archives
42 CFR §422.113(c)(2)
May 23, 2020 3:39 pm(iii) Is financially responsible for post-stabilization care services obtained within or outside the MA organization that are not pre-approved by... View more
42 USC § 1395ddd (f)(2)
May 23, 2020 3:38 pm(2) Limitation on recoupment (A) In general In the case of a provider of services or supplier that is determined... View more
42 CFR §422.568(e)
May 23, 2020 3:33 pmThe notice of any denial under paragraph (d) of this section must – (1) Use approved notice language in a... View more
42 CFR §422.113(b)
May 23, 2020 3:27 pm(2) MA organization financial responsibility. The MA organization is financially responsible for emergency and urgently needed services— (i) Regardless of... View more
Veterans Health Administration
May 15, 2020 4:12 pmVHA Script – Medical Necessity – Qualified Reviewers
May 15, 2020 4:05 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 – Maternity Coverage
May 15, 2020 4:02 pmASK YOURSELF: Did we verify eligibility? IF SO, WHAT DATE? Did the VA make negligent misrepresentation of the patient’s eligibility?... View more
VHA Script – Interest Owed on Late Claims
May 15, 2020 3:59 pmASK YOURSELF: What date was the claim initially billed? What date as the claim paid? Did they pay this claim... View more
VHA Affidavit – Medical Necessity – Qualified Reviewers
May 15, 2020 3:55 pmAFFIDAVIT OF COMPLIANCE Medical Necessity Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: ... View more