
Appeal Process Flashcard
Flashcard
•
English
•
12th Grade
•
Practice Problem
•
Hard
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14 questions
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1.
FLASHCARD QUESTION
Front
What is an appeal in the context of healthcare claims?
Back
An appeal is a formal request made by a member to review and overturn a denial of a claim, often based on the argument that the service was medically necessary.
2.
FLASHCARD QUESTION
Front
What type of appeal involves a denial where clinical review was involved?
Back
A clinical appeal.
3.
FLASHCARD QUESTION
Front
What information must be documented in the 'who' box for a verbal DOR (Designation of Representative)?
Back
The name and relationship of the caller.
4.
FLASHCARD QUESTION
Front
What is the role of member services when a member wants to appeal?
Back
Member services must fully explain the appeal process to the member and assist them politely.
5.
FLASHCARD QUESTION
Front
What can happen if an appeal is received without the required form?
Back
The appeal may be closed.
6.
FLASHCARD QUESTION
Front
What does DOR stand for in the context of appeals?
Back
Designation of Representative.
7.
FLASHCARD QUESTION
Front
What is the purpose of the appeal process in healthcare?
Back
The appeal process allows members to contest denials of claims and seek a review of the decision.
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