VHA Appeal – Interest Owed on Late Claims
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to properly reimburse emergency and/or authorized medically necessary services and care as required by federal law. Per the VA website, “the VA must make every effort to adjudicate... View more
VHA Appeal – Maternity Coverage
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to provide coverage for maternity services and care as required by Federal law. Our investigation has concluded the following: The VA has a duty to provide all maternity-covered... View more
VHA Appeal – Medical Necessity – Qualified Reviewers
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to reimburse medically necessary services as required by Federal law. Our investigation has concluded the following: Please be advised that 38 CFR §17.1006 states: “The Chief of the... View more
VHA Appeal – No Authorization for ER Services and Care
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to reimburse emergency services as required by Federal law. Our investigation has concluded the following: As you are aware, “to the extent allowable the VA will issue payment... View more
VHA Appeal – Notice Requirements for Adverse Determinations
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to reimburse medically necessary services as required by Federal law. Our investigation has concluded the following: Please be advised that 38 CFR §17.1006 states: “The Chief of the... View more
VHA Appeal – Poststabilization Timeframe
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to reimburse post-stabilization services as required by Federal law. Our investigation has concluded the following: THIS CLAIM IS NOW DAYS IN VIOLATION OF THE STATUTORY TIMEFRAMES. The VA... View more
VHA Appeal – Retroactive Denial for Authorized Care
Last Updated: November 23, 2021 | Letter Type: Appeals | Jurisdiction: VHA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the VA Under Secretary for Health for the VA’s failure to reimburse authorized services and care as required by Federal law. Our investigation has concluded the following: Under existing federal law, the VA has a duty to reimburse... View more
VHA Fax Cover Sheet – Request for Authorization of Emergency Services
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: VHA
REQUEST FOR AUTHORIZATION TO PROVIDE EMERGENCY SERVICES On , you notified our facility that further post-stabilization care was denied. This notice serves as a formal NOTICE OF DISAGREEMENT OF CARE. : Federal regulations state that you may authorize emergency services if notification (1) is made within 72-hours of... View more
WA HMO Fax Cover Sheet – Competent Reviewer Request
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: WA HMO
COMPETENT REVIEWER REQUEST : Washington law requires that there is a right to request the identity of the experts who were consulted about the adverse benefit determination—even if the expert’s advice was not used to make the determination, per WAC 284-43-3070. The carrier must provide, at minimum, the expert’s... View more
WA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: WA HMO
REQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1) provide post-stabilization authorization, or (2) enter into a disagreement of care and arrange for the transfer of the patient within 60 minutes from receipt of this notification, per 42 CFR §422.113 and 42 CFR §... View more