MO HMO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Jurisdiction: MO HMO
ASK YOURSELF: Was the coverage terminated? Did we verify eligibility? If so, what date and time? Did the plan make negligent misrepresentation of the patient’s eligibility? Did we get a reference/tracking or authorization number from the health plan? If so, what date and time? Did we treat pursuant to the plan’s verification and authorization in... View more
MO HMO Script – Untimely Payment
Last Updated: October 15, 2021 | Jurisdiction: MO HMO
ASK YOURSELF: What date was the claim initially billed? Was there any written communication (request for information, denial, underpayment) from the payor? IF SO, WHEN? HOW LONG AFTER THE CLAIM WAS BILLED? How many days is the plan in violation of the above prompt pay statute? Did they underpay the claim LATE, without the required... View more
NJ HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: NJ 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? How many days is the plan in violation of the prompt payment statute (N.J. Admin. Code §11:22-1.6(a))? The staff will be tactful and professional in communicating with the... View more
NJ HMO Script – Maternity Coverage
Last Updated: October 21, 2021 | Jurisdiction: NJ HMO
ASK YOURSELF: Did we verify eligibility? IF SO, WHAT DATE? Did the plan make negligent misrepresentation of the patient’s eligibility? Did the plan deny maternity coverage for no authorization? Is the plan refusing to comply with N.J. Admin. Code §11:24-5.2(a)(3)? The objective is to bring the plan into compliance with state law designed to benefit... View more
NJ HMO Script – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Jurisdiction: NJ HMO
ASK YOURSELF: What date was the request for non-urgent authorization made? Was there any written communication (request for information, denial, etc.) from the payor? If so, how long after the request was made did you receive any written communication? How many days is the plan in violation of the statutory authorization timeframe under N.J. Admin.... View more
NJ HMO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: NJ HMO
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? Did the written denial include specific reasons for... View more
NJ HMO Script – Poststabilization Timeframe
Last Updated: October 21, 2021 | Jurisdiction: NJ HMO
ASK YOURSELF: When was the patient stabilized in the emergency room or admitted as an inpatient? Was the admission during normal business hours (M-F, etc?) Did the hospital make initial contact with the plan successfully? Who did they speak with? Was a reference/tracking or authorization number provided by the plan? If so, what date and... View more
NJ HMO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: NJ HMO
ASK YOURSELF: How many days after payment, did the HMO 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
NJ HMO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Jurisdiction: NJ HMO
ASK YOURSELF: Was the coverage terminated? Did we verify eligibility? If so, what date and time? Did the plan make negligent misrepresentation of the patient’s eligibility? Did we get a reference/tracking or authorization number from the health plan? If so, what date and time? Did we treat pursuant to the plan’s verification and authorization in... View more
NJ HMO Script – Untimely Payment
Last Updated: October 21, 2021 | Jurisdiction: NJ HMO
ASK YOURSELF: What date was the claim initially billed? Was there any written communication (request for information, denial, underpayment) from the payor? IF SO, WHEN? HOW LONG AFTER THE CLAIM WAS BILLED? How many days is the plan in violation of the above prompt pay statute? Did they underpay the claim LATE, without the required... View more