Appeal Process Flashcard

Front

What is the purpose of obtaining HIPAA verification during a verbal DOR process?

Back

To ensure compliance with privacy regulations and protect patient information.

Front

What can happen if an appeal is submitted without the required form or if the verbal DOR process is not properly documented?

Back

The appeal may be closed.

Front

What does 'Pre-Service' refer to in the context of healthcare services?

Back

It refers to the service type before the member had the service.

Front

If a member's claim is denied as not medically necessary, what type of request is this considered?

Back

An Appeal.

Front

What is a Clinical appeal?

Back

It involves a denial where clinical review was involved.

Front

What is the significance of the verbal DOR process in the appeal process?

Back

It is a necessary step to document the appeal and ensure all required information is collected.

Front

What does DOR stand for in the context of appeals?

Back

DOR stands for 'Denial of Request'.

Front

What are the potential outcomes of an appeal process?

Back

The appeal can be upheld, overturned, or closed.

Front

What information is typically required to complete an appeal?

Back

The required form, documentation of the verbal DOR process, and any supporting evidence.

Front

What role does clinical review play in the appeal process?

Back

It assesses the medical necessity of the services provided and determines if the denial was justified.