CA Medi-Cal Script – ETAR Authorization Timeframes
Last Updated: September 3, 2020 | Jurisdiction:
ASK YOURSELF: What date was the ETAR faxed or uploaded? 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 Welfare & Institutions... View more
CA PPO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: CA PPO
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 Ins. Code §10123.13(a))? The staff will be tactful and professional in communicating with the payer when... View more
CA PPO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: CA PPO
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 Ins. Code §10123.135(e)? Did the written denial... View more
CA PPO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: CA PPO
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
CA PPO Script – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Jurisdiction: CA PPO
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 Ins. Code... View more
CA PPO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: CA PPO
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 Ins. Code §10123.135(h)(4)? Did the written denial... View more
CA PPO Script – Patient not Eligible
Last Updated: August 30, 2020 | Jurisdiction: CA PPO
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 an authorization or tracking number? IF SO, WHAT DATE? Did we treat pursuant to the plan’s verification and authorization in good faith? Is the plan refusing to comply... View more
CA PPO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: CA PPO
ASK YOURSELF: How many days after payment, did the insurer 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 provider... View more
CA PPO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Jurisdiction: CA PPO
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
CA PPO Script – Untimely Filing
Last Updated: August 30, 2020 | Jurisdiction: CA PPO
ASK YOURSELF: Is this claim or appeal “truly” filed late or has the plan mishandled the initial timely submission of the claim/appeal? (If the claim is “truly” filed late, proceed to next bullet point, if not see NO CLAIM ON FILE policy.) When was the patient discharged? What date was the claim billed and to... View more