Appeal Process Flashcard

Front

What is an appeal in the context of member claims?

Back

An appeal is a formal request made by a member to review and overturn a decision regarding their claim, particularly when it has been denied as not medically necessary.

Front

What should member services do when a member wants to appeal?

Back

Member services should fully explain the appeal process to the member and assist them politely.

Front

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

Back

The appeal may be closed if it is received without the required form or if the verbal DOR process isn't completed or correctly documented.

Front

What is the purpose of verbal authorization in the appeal process?

Back

The purpose of verbal authorization is to ensure that all interactions are completed from end to end.

Front

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

Back

A clinical appeal involves a denial where clinical review was part of the decision-making process.

Front

What is a grievance in the context of member services?

Back

A grievance is a formal complaint made by a member regarding dissatisfaction with services or decisions, which is different from an appeal.

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What is an expedited appeal?

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An expedited appeal is a faster process for reviewing an appeal when a member's health is at risk or when a timely decision is critical.

Front

What does DOR stand for in the appeal process?

Back

DOR stands for 'Documentation of Request,' which is a process to ensure that all necessary information is collected for an appeal.

Front

What is the difference between an administrative appeal and a clinical appeal?

Back

An administrative appeal deals with procedural issues, while a clinical appeal involves a review of medical necessity and clinical decisions.

Front

What role does documentation play in the appeal process?

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Documentation is crucial in the appeal process as it provides evidence and support for the claims being made and ensures compliance with procedures.