AL HMO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: AL 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 Ala. Code §27-3A-5(a)(4)(a)? Did the written denial... View more
AL HMO Script – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Jurisdiction: AL 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 Ala. Code... View more
AL HMO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: AL 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 Ala. Code §27-3A-5(a)(4)(a)? Did the written denial... View more
AL HMO Script – Poststabilization Timeframe
Last Updated: October 7, 2021 | Jurisdiction: AL 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
AL HMO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: AL 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
AL HMO Script – Untimely Payment
Last Updated: October 7, 2021 | Jurisdiction: AL 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
CA HMO Script – COB Denial
Last Updated: August 30, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: What date was the claim initially billed? Was there any written communication (request for information, denial) from the payor? IF SO, WHEN—HOW LONG AFTER THE CLAIM WAS BILLED? What information/document is pending which has resulted in reimbursement delay? How many days is the plan in violation of the prompt pay statute? The objective... View more
CA HMO Script – Concurrent Disagreement of Care
Last Updated: November 10, 2020 | Jurisdiction: CA HMO
ASK YOURSELF: Has the patient been stabilized in the emergency room or admitted as an inpatient? Did the hospital make initial contact with the plan (phone call, fax, online portal, etc.) successfully to request authorization? Who did they speak with (name and title)? Was an authorization or tracking number given? IF SO, WHAT DATE? If... View more
CA HMO Script – Contract Underpayment
Last Updated: November 19, 2021 | Jurisdiction: CA HMO
ASK YOURSELF: Are we contracted with the plan? IF SO, WHAT IS THE EXPECTED REIMBURSEMENT? 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 regulation 28... View more
CA HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: CA 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 statute (28 CCR §1300.71(g))? The staff will be tactful and professional in communicating with the payer when... View more