Appeal Process Quiz

Member services is expected to do what when a member wants to appeal?

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

• Ignore the appeal process and focus on new claims.

• Only provide written instructions for appeals.

• Direct members to a third-party service for appeals.

What type of appeal involves a denial where clinical review was involved?

• Administrative

• Clinical

• Contractual

• Reconstructive

What "Service Type" would you select if a member wants to appeal a denied prior authorization for a service they haven't had yet?

• Post-Service

• Pre-Service

• Both Pre-Service and Post-Service

• Neither Pre-Service nor Post-Service

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

• The appeal may be closed

• The appeal is automatically approved

• The appeal is ignored

• The appeal is expedited

Tags

CCSS.RI.11-12.1

According to the KM document what is the purpose of the Verbal Authorization/DOR for appeals?

• To allow the member to speak freely

• To ensure all interactions are completed from end to end

• To verify the caller's identity

• To document the call

Tags

CCSS.RI.11-12.6

Select the key words that would qualify for an expedite appeal/grievance.

• My doctor is wrong on my ID Card

• I need this cancer infusion

• I'm in debilitating Pain

• My claim processed as out of network, but my doctor referred me to this lab

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

• [e-mail]

• [e-mail]

• [e-mail]

• [e-mail]

Select all that must be documented in the "who" box for a Verbal DOR

• Name and relationship of the caller

• What the caller wants Anthem to do as a result of the appeal

• What is being appealed

• Name and OE US Domain of the rep that took the call

Select the correct scenario for a Standard Grievance.

• The member is upset because the provider's office is not clean

• The member calls because they are not able to find their virtual ID card

• The member is upset because they had to wait 10 minutes for a live person

• The member calls because their prior authorization was approved 

Member's claim has denied as not medically necessary, this would be what type of request?

• Grievance

• Expedited Grievance

• Appeal

• Expedited Appeal