MA Script – Misdirected Claims
Last Updated: May 24, 2020 | Jurisdiction: MA
ASK YOURSELF: Which entity was billed initially (the plan or capitated provider?) What date was the claim was initially billed? Did the entity who received the claim in error follow the rules listed below? Are the two entities still in disagreement over payment responsibility? If the capitated provider is financially responsible? How many days is... View more
MA Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: MA
ASK YOURSELF: What was the patient’s presenting symptoms or chief complaint in the emergency room? Did the plan pay for the medical screening, examination and evaluation necessary to determine if medical emergency exists? What criteria (final diagnosis code, etc.) did the plan rely upon to determine these services as “non-emergent?” The staff will be firm... View more
MA Script – No Claim on File
Last Updated: May 24, 2020 | Jurisdiction: MA
ASK YOURSELF: Was the claim billed electronically or physically? What date was the claim initially billed? Do we have a clearing house receipt confirming delivery? The staff will be tactful and professional in communicating with the payer when making this firm call and request immediate compliance to the applicable code section: Hi, my name is... View more
MA Script – No Contract Underpayment
Last Updated: November 19, 2021 | Jurisdiction: MA
ASK YOURSELF: Make sure we are contracted with the plan. What date was the claim initially billed? When did the plan underpay the claim? Did they underpay the claim LATE, without the required statutory interest? How many days is the plan in violation of the above prompt pay statute? What type of underpayment is it... View more
MA Script – Notice Requirements for Adverse Determinations
Last Updated: May 25, 2020 | Jurisdiction: MA
ASK YOURSELF: Who denied the claim? What is the professional’s license number with the State Medical Board? Were they a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider per 42 CFR §422.566(d)? Did the written denial... View more
MA Script – Poststabilization Timeframe
Last Updated: November 20, 2021 | Jurisdiction: MA
ASK YOURSELF: When was the patient stabilized in the emergency room or admitted as an inpatient? Was it during normal business hours (M-F, etc?) Did the hospital make initial contact with the plan successfully? Who did they speak with? Was an authorization or tracking number given? IF SO, WHAT DATE? If not, did the plan... View more
MA Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: MA
ASK YOURSELF: How many days after payment, did the MA plan request the refund? Why did the plan request the money back? Were services pre-approved and rendered in good faith? Were services statutorily authorized due to (plan’s) failure to approve or disapprove care within the required time frame? Is the recovery request lawful? Did the... View more
MA Script – Retroactive Denial for Authorized Care
Last Updated: May 24, 2020 | Jurisdiction: MA
ASK YOURSELF: Was the coverage terminated? Did we verify eligibility? IF SO, WHAT DATE? Did the plan make negligent misrepresentation of the patient’s eligibility? Did we get an authorization or tracking number? IF SO, WHAT DATE? Did we treat pursuant to the plan’s verification and authorization in good faith? Is the plan refusing to comply... View more
MA Script – Untimely Filing
Last Updated: October 26, 2021 | Jurisdiction: MA
ASK YOURSELF: Is this claim or appeal “truly” filed late or has the plan mishandled the initial timely submission of the claim/appeal? (If the claim is “truly” filed late, proceed to next bullet point, if not see NO CLAIM ON FILE policy.) When was the patient discharged? What date was the claim billed and to... View more
MI HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: MI HMO
ASK YOURSELF: What date was the claim initially billed? What date was the claim paid? Did the plan pay this claim LATE without the required statutory interest? Did they underpay the claim LATE, without the required statutory interest? How many days is the plan in violation of the prompt payment statute (MCL §500.2006(8)(a))? The staff... View more