FL HMO Script – Poststabilization Timeframe
Last Updated: May 5, 2021 | Jurisdiction: FL 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? Was a reference, tracking, or authorization number given? IF SO, WHAT DATE? Did the Payor or primary care physician attempt to... View more
FL HMO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: FL 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
FL HMO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Jurisdiction: FL 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
FL HMO Script – Untimely Payment
Last Updated: May 5, 2021 | Jurisdiction: FL 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
GA HMO Script – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Jurisdiction: GA HMO
ASK YOURSELF: What date was the claim initially billed? What date was the claim paid? Did the plan pay this claim LATE without the required statutory interest? How many days is the plan in violation of the prompt payment statute (GA Code §33-24-59.14(b)(1))? The staff will be tactful and professional in communicating with the payer... View more
GA HMO Script – Maternity Coverage
Last Updated: October 15, 2021 | Jurisdiction: GA 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 GA Code §33-24-58.2(b-c)? The objective is to bring the plan into compliance with state law designed to benefit the... View more
GA HMO Script – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Jurisdiction: GA 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
GA HMO Script – Refund Recoupment
Last Updated: November 20, 2021 | Jurisdiction: GA 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
GA HMO Script – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Jurisdiction: GA HMO
ASK YOURSELF: Was the coverage terminated? Did we verify eligibility? If so, what date and time? Did the plan make negligent misrepresentation of the patient’s eligibility? Did we get a reference/tracking or authorization number from the health plan? If so, what date and time? Did we treat pursuant to the plan’s verification and authorization in... View more
GA HMO Script – Untimely Payment
Last Updated: October 15, 2021 | Jurisdiction: GA 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