OH HMO Appeal – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ‘s failure to reimburse emergency services as required by state law. Our investigation has concluded the following: As the services rendered were emergent, was not required to obtain authorization per Ohio Rev... View more
OH HMO Appeal – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ‘s failure to meet the timeframe and notice requirements for non-urgent authorization requests as required by state law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS IN VIOLATION OF... View more
OH HMO Appeal – Poststabilization Timeframe
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ’s failure to reimburse emergency and/or statutorily granted post-stabilization services and care as required by state law. Our investigation has concluded the following: TO DATE, HAS FAILED TO REIMBURSE EMERGENCY AND... View more
OH HMO Appeal – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ’s failure to properly reimburse medically necessary services as required by state law. Our investigation has concluded the following: Please be advised that must substantiate how it reached its overpayment determination... View more
OH HMO Appeal – Untimely Payment
Last Updated: October 15, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ‘s failure to remit timely payment on this claim as required by state law. Our investigation has concluded the following: Per Ohio Rev Code §3901.381(B)(1), was required to reimburse within the... View more
PA HMO Affidavit – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Interest Owed on Late Claims Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 40 P.S §991.2166(b), which... View more
PA HMO Affidavit – Maternity Coverage
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Maternity Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 31 Pa. Code §154.12(a), which states: (a)... View more
PA HMO Affidavit – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Medical Necessity – Competent Reviewer Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa. Code §9.705(c)(3)(i), which state:... View more
PA HMO Affidavit – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Emergency and Urgently Needed Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa. Code §9.672(b) which... View more
PA HMO Affidavit – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: PA HMO
AFFIDAVIT OF COMPLIANCE Timeframes for Authorization Requests – Non-Urgent Health Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 28 Pa.... View more