What is an appeal in the context of member claims?

Appeal Process Flashcard

Flashcard
•
English
•
12th Grade
•
Hard
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1.
FLASHCARD QUESTION
Front
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.
2.
FLASHCARD QUESTION
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.
3.
FLASHCARD QUESTION
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.
4.
FLASHCARD QUESTION
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.
5.
FLASHCARD QUESTION
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.
6.
FLASHCARD QUESTION
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.
7.
FLASHCARD QUESTION
Front
What is an expedited appeal?
Back
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.
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