Appeal Process Flashcard

Front

What is the correct email address for the G&A team when sending additional information or a member's request to cancel?

Back

[e-mail]

Front

What must be obtained when completing a verbal DOR?

Back

HIPPA Verification

Front

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

Back

Appeal

Front

What is the purpose of verbal authorization according to the document?

Back

To ensure all interactions are completed from end to end

Front

What must be documented in the 'who' box for a verbal DOR?

Back

Name and relationship of the caller

Front

What is a verbal DOR?

Back

A verbal Document of Record (DOR) is a process to document verbal communications regarding member requests.

Front

What is the difference between a grievance and an appeal?

Back

A grievance is a complaint about the service or treatment, while an appeal is a request to review a denied claim.

Front

What does HIPAA stand for?

Back

Health Insurance Portability and Accountability Act.

Front

What is the significance of documenting the reason for an appeal?

Back

It provides context and justification for the request to review the denied claim.

Front

What information is typically included in a verbal DOR?

Back

Details of the call, including the caller's identity, reason for the call, and any actions taken.