Provider: Appeals Quiz

A provider is billing for a service that has already been completed but was not a covered benefit of the plan. The service was denied, and the provider submitted an appeal. What kind of appeal is this?

• Clinical

• Non-clinical

• Expedited

• Escalated

Answer explanation

This is a non-clinical appeal because it addresses denial of a service that is not a covered benefit based on policy guidelines.

A member is appealing a Recommended Clinical Review denial because she says she has met medical policy criteria. What kind of appeal is this?

• Clinical

• Expedited

• Escalated

• Non-clinical

Answer explanation

This is a clinical appeal because it addresses the denial of a service that is covered on the plan.

A member requested an escalation of an appeal for a life-altering pain treatment that was denied because it was not covered under his plan. It has been in review for 15 days. Which type of appeal is this request eligible for?

• Expedited appeal

• Escalated appeal

• Both Expedited and Escalated appeals

• Neither Expedited or Escalated appeals

Answer explanation

The appeal is not eligible for expedition because it is non-clinical. It is also ineligible for escalation because it has only been in review for 15 days. 

A provider requested an escalation of an appeal for a cosmetic service that was denied as not covered. The claim has been in review for 40 days. Which type of appeal is this request eligible for?

• Expedited appeal

• Escalated appeal

• Both Expedited and Escalated appeals

• Neither Expedited or Escalated appeals

Answer explanation

This appeal is not eligible for expedition because it is non-clinical, but it can be escalated because it has been over 30 days. 

A MAR requested an escalation of an appeal for a life-saving treatment that was denied for medical policy during Recommended Clinical Review. It has been 2 days. Which type of appeal is this request eligible for?

• Expedited appeal

• Escalated appeal

• Both Expedited and Escalated appeals

• Neither Expedited or Escalated appeals

Answer explanation

The appeal can be expedited because it is clinical and critical to the member’s wellbeing.

Is a provider-submitted appeal eligible for a second level review if the member has also submitted an appeal?

• Yes

• No

Answer explanation

Provider appeals are never eligible for a second level review. 

Is a MAR-submitted appeal eligible for external review if the member appeals are exhausted, but the provider has not submitted an appeal?

• Yes

• No

Answer explanation

The provider will need to exhaust the appeal first.