Appeal Process Flashcard

Front

What happens if an appeal is received without the required form or the verbal DOR process isn't completed/correctly documented?

Back

The appeal may be closed.

Front

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

Back

Name and relationship of the caller.

Front

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

Back

Appeal.

Front

What is expected of member services when a member wants to appeal?

Back

Fully explain the appeal process to the member and assist politely.

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

Define 'Appeal' in the context of member services.

Back

A formal request for reconsideration of a decision made regarding a claim.

Front

What is a 'Grievance' in member services?

Back

A complaint about the quality of care or service received.

Front

What does DOR stand for in the appeal process?

Back

Document of Record.

Front

What is the purpose of documenting the 'who' box in a verbal DOR?

Back

To identify the caller and their relationship to the member.

Front

What is the difference between an 'Expedited Appeal' and a regular 'Appeal'?

Back

An expedited appeal is processed faster due to urgent medical needs.