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 Affidavit – Interest Owed on Late Claims
Last Updated: January 22, 2025 | Letter Type: Affidavits | Jurisdiction: WA 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 Plan or Contracted Entity has met the provisions of Washington... View more
WA HMO Affidavit – Maternity Coverage
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA 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 Plan or Contracted Entity has met the provisions of Revised Code of Washington (RCW)... View more
WA HMO Affidavit – Medical Necessity – Qualified Reviewers
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA HMO
AFFIDAVIT OF COMPLIANCE Medical Necessity 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 Plan or Contracted Entity has met the provisions of Washington Administrative Code 284-43-3110(6),... View more
WA HMO Affidavit – No Authorization for ER Services and Care
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA 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 Plan or Contracted Entity has met the provisions of Revised Codes... View more
WA HMO Affidavit – Non-urgent Authorization Timeframes
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA 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 Plan or Contracted Entity has met the... View more
WA HMO Affidavit – Notice Requirements for Adverse Determinations
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA HMO
AFFIDAVIT OF COMPLIANCE Notice Requirements for Adverse Determinations 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 Plan or Contracted Entity has met the provisions of Washington Administrative... View more
WA HMO Affidavit – Poststabilization Timeframe
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA HMO
AFFIDAVIT OF COMPLIANCE Poststabilization Care 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 Plan or Contracted Entity has met the provisions of Revised Code of Washington §48.43.093,... View more
WA HMO Affidavit – Refund Recoupment
Last Updated: January 21, 2025 | Letter Type: Affidavits | Jurisdiction: WA HMO
AFFIDAVIT OF COMPLIANCE Recoupment 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 Plan or Contracted Entity has met the provisions of Revised Code of Washington (RCW)... View more