Appeal Process Quiz

Member services is expected to do what when a member wants to appeal and verbal appeals are allowed for a DMHC policy?

• 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

Member services is expected to do what when a caller wants to appeal and verbal appeals are allowed for a DMHC policy?

• Ignore the appeal process and focus on new claims.

• Fully explain the appeal process and complete the verbal DOR process

• Only provide written instructions for appeals 

• Direct member to a third party service for appeals

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.11-12.3

CCSS.RI.11-12.5

CCSS.RI.8.3

CCSS.RI.9-10.3

CCSS.RI.9-10.5

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]

Member services is expected to do what when assisting a caller with a claim that needs to be adjusted and verbal appeals are allowed for a DMHC policy?

• Ignore the claim adjustment request and focus on claims that don't require adjustment

• Complete the verbal DOR process and send the claim for adjustment

• Advise request would need to be submitted in writing

• Send the claim for adjustment nothing else is needed.

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