Downgrade LifePoint

Choose the right example for Operational Error from the given options-

• ·Late Notification/Clinicals Not Sent Timely- Payer was not notified within contracted guidelines of pt admission

• Notification/Clinicals sent timely, however payer denies request due to not meeting payer IP Criteria.

• ·Auth was approved in advance of scheduled IP stay, and denied for Medical Necessity.

• ·Extended Stays- Case management requests additional days to be added to authorized IP stay and sends all required information, however payer denies additional days due to medical necessity.

Which one of the following is an example of an inappropriate downgrade?

• Credentialing Issue

• Lack of notification to Insurance

• Date of Service issues

• All the above

The Downgrade Process is usually followed when we receive an operational error denial related to Authorization or Medical Necessity

• True

• False

True or False: In the case of partial payment account should not be sent for downgrade.

• True

• False

True or False: In the case of authorization or medical necessity denial, if both appeals were upheld, then the associate needs to check the TFL before sending the claim for downgrade.

• True

• False