ERISA Script – Maternity Coverage
Last Updated: November 21, 2021 | Jurisdiction: ERISA
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 29 CFR §2590.711? The objective is to bring the plan into compliance with federal law designed to benefit the... View more
ERISA Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: ERISA
ASK YOURSELF: Who denied the claim? 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 29 CFR §2560.503-1 (g)? What is the professional’s license number with the California Medical Board? Did the written... View more
ERISA Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: ERISA
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
ERISA Script – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Jurisdiction: ERISA
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 29 CFR... View more
ERISA Script – Notice Requirements for Adverse Determinations
Last Updated: May 24, 2020 | Jurisdiction: ERISA
ASK YOURSELF: Who denied the claim? 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 29 CFR 2560.503 (g)? What is the professional’s license number with the California Medical Board? Did the written... View more
FL HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: FL 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 (37 §Fla. Stat. §627.613(2)? The staff will be tactful and professional in communicating with the payer... View more
FL HMO Script – Maternity Coverage
Last Updated: May 6, 2021 | Jurisdiction: FL 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? Were the services rendered in response to an emergency condition as defined by 37 Fla. Stat. §541.47(7)? Is the plan refusing to comply with 37 Fla.... View more
FL HMO Script – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Jurisdiction: FL 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 37 Fla. Stat. §641.51(4)? Did the written denial... View more
FL HMO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: FL 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
FL HMO Script – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Jurisdiction: FL 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 37 Fla. Stat. §641.51(4)? Did the written denial... View more