Appeal Process Flashcard

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.

Front

What type of appeal involves a denial where clinical review was involved?

Back

A clinical appeal.

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.

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.

Front

What can happen if an appeal is received without the required form?

Back

The appeal may be closed.

Front

What does DOR stand for in the context of appeals?

Back

Designation of Representative.

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.

Front

What is a verbal DOR?

Back

A verbal DOR is a process where a member verbally designates another person to act on their behalf in the appeal process.

Front

What are the potential outcomes of an appeal?

Back

The appeal can be upheld, overturned, or denied.

Front

What is the significance of documenting the appeal process?

Back

Documenting the appeal process ensures transparency, accountability, and compliance with regulations.