NV HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: NV 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 (Nevada Revised Statute §695C.185(1))? The staff will be tactful and professional in communicating with the... View more
NV HMO Script – Maternity Coverage
Last Updated: October 21, 2021 | Jurisdiction: NV 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 Nevada Revised Statute 689A.717(1-3)? The objective is to bring the plan into compliance with state law designed to benefit... View more
NV HMO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: NV 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 per of Nevada Revised Statute 695G.150? Did the... View more
NV HMO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: NV HMO
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
NV HMO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: NV 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 per Nevada Revised Statute §695G.150? Did the written... View more
NV HMO Script – Untimely Payment
Last Updated: October 21, 2021 | Jurisdiction: NV 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
NY HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: NY HMO
ASK YOURSELF: What date was the claim initially billed? What date was the claim paid? Did they pay this claim LATE without the required statutory interest? How many days is the plan in violation of the prompt payment law (NY Ins L §3224-a(a))? The staff will be tactful and professional in communicating with the payer... View more
NY HMO Script – Maternity Coverage
Last Updated: May 5, 2021 | Jurisdiction: NY 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 NY Ins L §3221(k)(5)(A)(i)? The objective is to bring the plan into compliance with state law designed to benefit... View more
NY HMO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: NY 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 per NY Ins L §4904(d)? Did the written... View more
NY HMO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: NY HMO
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