VHA Script – Maternity Coverage
Last Updated: November 23, 2021 | Jurisdiction: VHA
ASK YOURSELF: Did we verify eligibility? IF SO, WHAT DATE? Did the VA make negligent misrepresentation of the patient’s eligibility? Did the VA deny maternity coverage for no authorization? Is the VA refusing to comply with the 38 CFR §17.38(a)? The objective is to bring the VA into compliance with federal law designed to benefit... View more
VHA Script – Medical Necessity – Qualified Reviewers
Last Updated: November 23, 2021 | Jurisdiction: VHA
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 38 CFR §17.1006? Did the written denial... View more
VHA Script – No Authorization for ER Services and Care
Last Updated: November 23, 2021 | Jurisdiction: VHA
ASK YOURSELF: What was the patient’s presenting symptoms or chief complaint in the emergency room? Did the VA pay for the medical screening, examination and evaluation necessary to determine if medical emergency exists? What criteria (final diagnosis code, etc.) did the VA rely upon to determine these services as “non-emergent?” The staff will be firm... View more
VHA Script – Notice Requirements for Adverse Determinations
Last Updated: November 23, 2021 | Jurisdiction: VHA
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 38 CFR §17.1006? Did the written denial... View more
VHA Script – Poststabilization Timeframe
Last Updated: November 23, 2021 | Jurisdiction: VHA
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 VA successfully? Who did they speak with? Was an authorization or tracking number given? IF SO, WHAT DATE? If not, did the VA... View more
VHA Script – Retroactive Denial for Authorized Care
Last Updated: November 23, 2021 | Jurisdiction: VHA
ASK YOURSELF: What date was the claim initially billed? Is there an Authorization on file? Were the services rendered consistent with the authorization provided? Is the VA ultimately denying this claim as “not authorized”? The staff will be tactful and professional in communicating with the payer when making this firm call and request immediate compliance... View more