TX HMO Script – Maternity Coverage
Last Updated: May 5, 2021 | Jurisdiction: TX 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 8 TIC §1366.055(a)? The objective is to bring the plan into compliance with state law designed to benefit the... View more
TX HMO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: TX 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 6 TIC §843.253(b)? Did the written denial... View more
TX HMO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: TX 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
TX HMO Script – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Jurisdiction: TX 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 6 TIC... View more
TX HMO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: TX 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
TX HMO Script – Poststabilization Timeframe
Last Updated: October 7, 2021 | Jurisdiction: TX HMO
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 a reference, tracking, or authorization number given? IF SO, WHAT DATE? If not, did the... View more
TX HMO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: TX 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
TX HMO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Jurisdiction: TX HMO
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 a reference, tracking, or authorization number? IF SO, WHAT DATE? Did we treat pursuant to the plan’s verification and authorization in good faith? Is the plan refusing to... View more
TX HMO Script – Untimely Payment
Last Updated: May 5, 2021 | Jurisdiction: TX 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
VHA Script – Interest Owed on Late Claims
Last Updated: November 23, 2021 | Jurisdiction: VHA
ASK YOURSELF: What date was the claim initially billed? What date as the claim paid? Did they pay this claim LATE, without the required statutory interest? How many days is the VA in violation of prompt payment? The staff will be tactful and professional in communicating with the payer when making this firm call and... View more