Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process"

Transcription

1 Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process

2 Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process Provided as a Service of Covidien Introduction: Your involvement is...02 Overview: What s behind the appeals process...03 Participants: Each player has a unique role...04 Your role as surgeon Your patient s role The role of the employer Levels of Appeal: How the process works Request for prior authorization st level appeal Strategies for 1st level appeals Outcomes of 1st level appeals 2nd level appeal Strategies for 2nd level appeals Outcomes of 2nd level appeals 3rd level appeal Strategies for 3rd level appeals Outcomes of 3rd level appeals Communication: Guidelines for a successful appeal Appendix Sample physician appeal letter - Outline of Content For quick reference: Appeals process summary Contacts during the appeals process: Sample log form Glossary of terms INTRODUCTION Your involvement is essential As you are probably aware, getting patients approved for Bariatric Surgery procedures can be a challenging task. Establishing a smooth and productive reimbursement process with your payers can consume much of your time and energy. The criteria for patient approval varies from carrier to carrier, but in general insurance company payments are determined by the number of procedures performed and the contracted fees negotiated with the surgeon and hospital and the Current Procedural Terminology (CPT) codes billed. As is often the case, the initial request for insurance coverage for the procedure may be denied. Typically denial falls into two categories: 1) Either the patients are having difficulty meeting the insurer s pre-surgical conditions or 2) the insurer is still of the mindset that bariatric surgery is too risky or investigational even after FDA approval, over 20 years of experience and 50,000+ completed cases worldwide. As a physician with your patient s best interests in mind, you have the authority, knowledge, and medical experience necessary to initiate an effective appeal and reverse a payer s decision. This guide is intended to provide general information and tools that can assist you to do just that. Leading an appeal will require greater involvement on your part, but its well worth the effort. A successful appeal based on the specific medical needs of your patient can make a real difference in his or her overall health and everyday life. Disclaimer and Exclusion of Liability [2]

3 Overview PARTICIPANTS What s behind the appeals process? Most healthcare plans take a cautious approach to new technologies or high risk or investigational surgery. A payer may choose to deny requests for insurance coverage until the healthcare plan has had an opportunity to conduct its own formal review known as a surgical or new technology assessment. This is a formal review of the procedure, its indications, exclusions and outcomes. An assessment can be conducted internally (within the payer s organization) or externally (by an independent review firm). Typically, a panel of experts is identified to review published literature, clinical trial results, costs, appropriate patient populations, and health outcomes associated with the requested procedure as well as general information about the disease indication. Members of the panel generally review the materials independently and then form a collective opinion. Though not binding, this opinion heavily influences a payer s decision to provide coverage for such procedures. If the assessment confirms that the Bariatric surgical procedure is a safe and effective treatment option for plan members, the process of obtaining insurance coverage for patients is relatively simple and straightforward similar to that required for other payer-approved treatments and procedures. Until a procedure for the patient is payer-approved, however, you and your patient may need to appeal for insurance coverage by providing additional information and arguments in support of the surgical procedure. The appeals process varies from plan to plan but may involve as many as three parties and three levels of appeal. As you initiate an appeal, keep in mind that any insured patient who is denied coverage is entitled to have his or her case reviewed. Most payers are regulated by state and/or federal laws designed to ensure that patients are treated fairly and equitably. These laws require healthcare plans to act honestly and in good faith in fulfilling their contractual obligations to their members. Most payers make every effort to do more than merely fulfill their legal obligations. They try to reasonably assess the needs of the individuals covered under their plans. Three parties are frequently involved in appealing a payer s decision to deny insurance coverage: you, your patient, and your patient s employer. Occasionally a patient advocate or advocacy group may also be helpful in championing the patient s case before the healthcare plan. Your role as surgeon Your knowledge and experience with the patient makes you the medical expert in the appeals process. You understand the unique medical needs of your patient; you are also in the best position to present a convincing case in favor of the recommended surgery and overturn a denial of coverage. Furthermore, through your leadership and partnership with the patient, you can help empower him or her to participate in the appeals process. You can also identify situations when it makes sense for the patient s employer or a patient advocate or advocacy group to get involved. Your patient s role As the individual with the most to gain or lose from the healthcare plan s decision, your patient should be encouraged to take an active role in the appeals process. There are a number of ways that your patient can become involved and influence the outcome of a payer s decision. These include: Obtaining the benefits booklet or other document containing the healthcare plan s guidelines and policies on the appeals process Personally contacting the healthcare plan to discuss a decision over the phone Writing a thoughtful appeal letter, one which outlines the impact of their obesity on their health and daily life and argues against the insurer s reasons for denial Asking for advice from the employer who sponsors the healthcare plan the role of the employer Most patients acquire healthcare insurance coverage through regular employment. The employer is considered the plan holder; the employee, the plan subscriber. Because employers represent large groups of members in the healthcare plan and can opt to switch plans if members are dissatisfied, employers can have a great deal of clout in the appeals process. Patients are likely to find that talking with the employer about a payer s decision and involving the Human Resources department in an appeal may prove useful in reversing a denial of coverage. Together you, your patient, and your patient s employer can be a powerful team in appealing a payer s decision to deny coverage. [3] [4]

4 APPEALS Levels of Appeal: How the process works. Request for prior authorization Generally, before a patient undergoes elective surgery, most healthcare plans require prior authorization of the procedure. For most procedures, your office staff requests prior authorization by phone. In the case of Bariatric surgery, however, you should have your staff submit a letter requesting prior authorization, also known as a letter of medical necessity. A letter of medical necessity should include the following information: Specific details of the patient s case history, duration and degree of illness/injury, and a summary of your and prior physicians clinical experience with the patient, including previous failed treatments A description of how the patient s condition affects his or her ability to work, conduct daily living functions, participate in activities designed to improve his or her clinical condition (i.e. exercise, physical therapy, weight loss programs), and ability to sleep are all good examples to include. A summary of the clinical evidence (i.e., published literature) that supports the safety and efficacy of Bariatric and associated surgical procedures as it relates to the patient s medical condition In addition, it is helpful to include documentation regarding the billing codes and a bibliography of relevant peer-reviewed published literature on the specific procedure. After you submit the letter of medical necessity, you or your office staff should receive the healthcare plan s written response, your patient may receive a copy of the response as well. If the healthcare plan approves your request for prior authorization, no further action is required. 1st level appeal If you or your patient receives a communication indicating a denial of coverage, you should consider initiating a formal appeal. Typically, the communication is in writing and originates from the designated plan s representative who has reviewed your request. The letter denying coverage should: Clearly state the reason(s) for the decision Refer to the healthcare plan provisions upon which the denial of coverage is based Indicate additional written material or information that can be submitted that might change the healthcare plan s decision Discuss the procedure for requesting an appeal of the decision If the denial letter does not include the information listed above, immediately submit a written request to the healthcare plan representative for this information. If you receive a denial letter with appropriate supporting information, it is important to take time to gain a thorough understanding of the payer s reason(s) for denial of coverage. Try to determine whether the denial involves: A medical issue (refusal to authorize surgery) An administrative issue (refusal of benefit due to lack of coverage) If you or the patient have questions or need further clarification, don t hesitate to contact the designated plan representative by phone to discuss the case and get the answers you need. Once you understand the reasons for denial of coverage, you and your patient can initiate an appeal formulated according to the instructions in the benefits booklet or those received directly from the healthcare plan. Keep in mind that, throughout the appeals process, reviews of your requests for coverage must be conducted according to regulations that govern the healthcare plan, which is overseen by state officials and, ultimately, the state Department of Insurance (DOI). During the appeals process, it is important that both you and your patient keep accurate records of all interactions with the healthcare plan and monitor the timeliness of the plan s response. (See sample form for recording this information enclosed.) Strategies for 1st level appeals Even though Bariatric Surgery is not new, it may still be considered a high risk procedure for some insurers. This may be due to actual safety concerns for their members, concern for their own return on investment or probably in most cases a little of both. There is still a lot of misinformation and prejudice surrounding obesity and who should pay for treatment. It is very important to continue the education process by providing information such as outcome data and the short and long term advantages associated with the latest bariatric procedures. Another common reason for initial denial of insurance coverage is the payer s general medical policy, which specifies that the treatment you request is not reimbursable? Typically, healthcare plans rely heavily on medical policy and apply it across the board to all members, without regard for individual circumstances. In this case, your strategy for a 1st appeal should be to request individual consideration. A request for individual consideration should be directed to the designated healthcare plan representative and should ask that the plan reconsider its decision in light of your patient s specific medical needs, rather than overall policy. Ideally, the request should include a letter from you with appropriate clinical documentation explaining your patient s medical needs, accompanied by a letter from your patient that explains why the surgery is necessary from his or her perspective. (See outline of sample letter.) If the plan responds with a favorable decision to your request for individual consideration, the decision will apply only to the patient in question not to all members of the plan. [5] [6]

5 Outcomes of 1st level appeals When you submit the 1st appeal or request for individual consideration, be aware that most healthcare plans follow a definite timeframe for appeals. If you or your patient fail to meet the timeline, the patient may lose the right to appeal. Generally, payers make every effort to adhere to their published timeframes. Nonetheless, it is good to keep track of the expected response date to the appeal. Regardless of when you receive the decision, the insurer should provide it in writing. If the plan issues a favorable decision, no further action is required on your part or on the patient s part prior to surgery. However, if your patient is denied insurance coverage again, most healthcare plans offer the opportunity for a 2nd level appeal. 2nd level appeal If a healthcare plan responds to the 1st appeal by denying coverage, the written communication you receive should contain the following information: the reason(s) for denial, documentation supporting the decision to deny coverage, an outline of the next steps in the appeals process, and the appropriate timeframe for the appeal. Again, you and your patient should carefully review this information, clarify any issues with the payer, and then strategize about how to proceed with the 2nd level appeal. Strategies for 2nd level appeals One common strategy for a 2nd level appeal is to write and request a full and fair review of your patient s case. This means: The case should be reviewed on its own individual merits and the patient s specific circumstances The review should be conducted by an independent physician who was not involved in the original decision to deny coverage The review should be done school to school; in other words, the physician reviewer, who: Works in the same specialty as the patient s surgeon, i.e., Bariatric and/or general surgery Is familiar with and perform bariatric, digestive or abdominal procedures -, laparoscopic and open Routinely treats patients with Morbid Obesity In addition, a full and fair review should allow direct discussion between you and the physician reviewer so that you can present specific facts to the reviewer about your patient s case as well as your rationale for treatment. Keep in mind, requesting a full and fair review is a good strategy; however, the healthcare plan is not obliged to comply with this request. Another common strategy for a 2nd level appeal is to involve the patient s employer and/or a patient advocate or advocacy group. A patient advocate or advocacy group helps bridge the gap between the patient and the payer. They work on behalf of the Patient advocacy groups that can assist with denials of coverage for Bariatric treatment and surgical procedures, include those associated with Obesity, Morbid Obesity and Metabolic Disorders. Outcomes of 2nd level appeals An insurer will usually render a decision on a 2nd level appeal within the timeframe specified in previous written communication or the benefits booklet. The insurer should provide written notification if the review takes longer than expected and should indicate the reason(s) for the delay as well as the anticipated date for the final decision. Throughout the appeals process, you and your patient can help prompt a faster response by requesting an expedited review and/or following up frequently with the designated representative of the healthcare plan. However, since Bariatric surgery is an elective procedure, the payer is not obligated to conduct an expedited review. In most instances, a denial of coverage for Bariatric Surgery after a 2nd level appeal will be based on the healthcare plan s opinion that the procedure is still investigational or that your documentation of the patient s efforts to meet the carrier s presurgical requirements has not been adequate. (ex. 6 months on a medically documented weight loss program) In other words, the plan believes that the amount or caliber of long-term data published in U.S. medical journals is insufficient to document the safety and efficacy of treatment or they are standing firm on their interpretation of the pre-surgical requirements they have outlined in their policies. 3rd level appeal Some healthcare plans permit a 3rd level appeal. Third level appeals can occur as much as 3 months after the initial request for prior authorization. Therefore, if any new clinical information is available on the surgical procedures or the patient has accumulated more documentation pertaining to their pre-surgical requirement this material should be included in the appeal. Strategies for 3rd level appeals At this stage of the appeals process, your patient should consider contacting the state Department of Insurance (DOI). Contact information for the state DOI can be found in the yellow pages of your phone directory under state government agencies. You can also source this information from the internet on the state s homepage. In addition, if your state has a local Office of the Ombudsman, your patient should get in touch with the office. The Ombudsman can provide additional information about avenues of appeal available to your patient and may sometimes act as a patient advocate. Typically, if after the 3rd level appeal, the healthcare plan continues to deny insurance coverage, you and your patient have exhausted all channels in the appeals process. If your patient wishes to further pursue insurance coverage, he or she can consider legal action. patient, championing the patient s cause with the healthcare plan. [7] [8]

6 COMMUNICATION Guidelines for a successful appeal In your ongoing communication with the healthcare plan, keep in mind that the appeal is about what is in the best interests of your patient. As the treating physician, your opinion is crucial in terms of determining which treatment is medically necessary for your patient. Here are some guidelines to keep in mind as you go through the appeal process for Bariatric Surgery: In all communication, written or verbal, be sure to identify and refer to the patient by name to humanize the process Clearly state your reasons for disputing the payer s decision Specifically address each point that the payer has used to deny your request for coverage Always make your appeal in your own words Be sure to refer to the patient s medical record and indicate the length of time that the patient has been in your or another physician s care regarding their obesity. Discuss all resulting co-morbidities, their severity and potential long term effects. Include the patient s medical history, physical exams, clinical evaluations, and verbal complaints Clearly demonstrate that the patient has failed to respond to all conservative measures with any consistency or any notable clinical improvement. Point out that, regardless of the plan s decision on coverage, your patient requires a therapeutic intervention; in this case, surgery Explain that the patient s condition is serious, that long-term success rates are best with surgery, and that the patient is committed to making this lifestyle change. State that your outcome data is positive and clinically effective. (Include your outcome data vs. national statistics if available) Cite any other specific clinical data that has led you to this decision and state, that for this particular patient Bariatric surgery is the treatment of choice Whenever possible, be sure to quote peer-reviewed published literature and statements from the patient s own benefits booklet to demonstrate how Bariatric Surgery meets the health plan s definition of a covered benefit. (NOTE: The bibliography in the Appendix lists published articles on obesity, metabolic issues, and Bariatric surgical procedures that are available for citation) Emphasize that, as the treating physician, your medical opinion regarding what is in the best interest of your patient should carry more weight than a chart review conducted by a well-meaning person who has limited knowledge of the patient and may not be familiar with the Bariatric surgical procedures. Point out that your treatment recommendations are based on your medical opinion as a highly qualified Bariatric surgeon, who has been in practice for a number of years (be sure to specify the number.) Mention that you have undergone training specifically focused on Bariatric surgery, including, fellowships, hands-on preceptorships, and lectures regarding surgical technique Whenever necessary, be sure to request an opportunity to speak directly with the physician reviewer assigned to the case [9] [10]

7 Appendix Sample physician appeal letter This outline suggests one method of organizing your appeal letter. Please remember that you should tell the patient s story and present your medical conclusions in your own words. [Date] [Individual Name, MD] [Insurance Company Name] [Insurance Address] [City, State, Zip] Re: Request for Reconsideration of a Denial of Coverage [Name of Patient] [Subscriber ID Number] Dear [Name of representative from healthcare plan]: Paragraph 1 State the name of the patient covered under the insurer s program State the date of the denial State that the procedure requested is the [Insert Type] Bariatric surgical procedure Paragraph 2 State the length of time that you have had [name of patient] in your care State that [name of patient] has a diagnosis consistent with the indications for Morbidly Obesity. Explain that all other previous non-surgical weight loss options for [name of patient] have failed Paragraph 3 State that, after discussion with [name of patient], it is your opinion that the most appropriate treatment option is the [Insert Type] Bariatric surgical procedure. Emphasize that this recommendation is not made lightly, given the nature of the planned surgery Paragraph 4 Point out that the Bariatric surgical procedure has extensive clinical experience behind it, noting: Large number of patients in the United States who have already received it Positive reported outcome data, low complication rates and high patient satisfaction Refer to any personal experience you have had performing this surgery, and to your Bariatric surgical training Paragraph 5 State that Medicare and a growing number of insurance companies are now covering Bariatric surgery. Most importantly, emphasize that [name of patient] meets the BMI criteria set by the National Institute of Health and that surgery is now being considered as an appropriate option for such patients by the American Academy of Family Physicians Paragraph 6 Mention the goals of surgery with the Bariatric Surgery: to achieve weight loss, improve other co-morbidities and the patient s overall quality of life. Restate your position that [name of patient] is an excellent candidate for this surgery and you support his or her request for an appeal of denial of coverage Paragraph 7 State that you believe that this case should be reviewed based on individual patient consideration and not on medical policy Request a full and fair, school-to-school review with the opportunity to discuss the case directly with the reviewer Paragraph 8 Conclude by stating that you trust that [name of payer] will grant an approval of this surgery so that together you can provide the best possible care to [name of patient] Add that, given the duration of [name of patient] s condition and his or her present quality of life you look forward to a timely reply Sincerely, [Physician name and signature] Enclosures: Copy of letter of appeal from [name of patient] Supporting clinical literature Medical records of [name of patient] [11] [12]

8 Appendix Appendix Quick reference - Appeals process summary Request for pre-authorization Write a letter to your patient s healthcare plan requesting insurance coverage for Bariatric Surgery. If the plan approves, no further action is required 1st level appeal If the insurer does not approve your pre-authorization request, both you and your patient should write appeal letters to the insurer. (See previous section s suggestions about the content of your letter) Potential strategies: Provide more details about the surgical benefits and clinical documentation to dispute any objections Submit a request for individual consideration, based on the merits of the case and the needs of your particular patient Contact the insurer s designated representative by phone to ask questions or clarify any issues If the plan approves, no further action is required 2nd level appeal If the first appeal is denied, you and the patient should write another letter to the insurer Potential strategies: Request a full and fair review by a physician not previously involved in the case Ask that the review be conducted school to school Request that the physician reviewer be knowledgeable about Bariatric Surgery Request an opportunity to discuss the case with the physician reviewer Work closely with the patient to get the patient s employer involved in the appeal Alternatively, involve a patient advocate or advocacy group in the appeal If the plan approves, no further action is required 3rd level appeal If the insurer continues to deny coverage, you and your patient will need to write a final letter to the insurer and appropriate state agencies, such as the DOI or Office of the Ombudsman Potential strategies: Initiate patient advocacy by contacting all appropriate local and state agencies Contact the patient s employer to find out whether the employer is willing to contact the payer and act as a patient advocate. (NOTE: You can offer to provide return-to-work and job productivity data to help increase the employer s willingness to participate in the appeal) Post 3rd level appeal Typically, if the 3rd level appeal proves unsuccessful, you and your patient have exhausted all steps in the appeals process. The patient can consider legal action. Contacts During the Appeals Process: sample log form Set Up Grid or Excel Spreadsheet for optimal tracking of contacts and progress. Your Name Type of Insurance Member/Group Number Appeals Case Numnber Type of Contact Request for Prior Authorization 1st Level Appeal 2nd Level Appeal 3rd Level Appeal Employer: Advocate / advocacy Group: Office of the Ombudsman: Other Call Date & Time Person Contacted: Name/Title Dept/Phone Issues Discussed & Outcomes Next Steps Date for Follow-up [13] [14]

9 Appendix: Glossary of terms Appeals process The process by which a patient seeks to overcome a healthcare plan s denial of insurance coverage for a medical technology or procedure and receive reimbursement for surgery. Typically, the process involves up to 3 levels of appeal and up to 3 parties. DOI Department of Insurance. As an organization within the federal government, this department oversees the functions of all healthcare plans and is the ultimate authority in the appeals process. Full and fair review A review of an appeal that is conducted by a physician who has not been involved in a payer s original decision to deny insurance coverage. During this type of review, the patient s case is examined primarily on its individual merits and the patient s individual circumstances. IDE Investigational device exemption. The exemption from FDA that allows companies to ship investigational products to hospitals to conduct clinical studies of the product. The clinical studies will be reviewed by FDA to determine whether the device can be marketed in the US. Letter of medical necessity Written by the treating physician, this letter attempts to prove that the requested procedure or technology is necessary for a specific patient. Generally, the letter includes details and a history of the patient s case, a description of how the patient s condition affects his or her activities of daily living, and published literature that supports the safety and efficacy of a new technology or procedure. Medical policy Reimbursement guidelines and procedures that govern all members of a healthcare plan. Office of the Ombudsman A government office available in certain states only. The Ombudsman can assist in the appeals process by suggesting additional avenues for appeal and can also act as a patient advocate. Patient advocate An advocate or advocacy group champions the patient s case before the healthcare plan and helps bridge the gap between the patient and the payer. Patient advocates can often be very effective in helping to overturn a denial of insurance coverage. Patient benefits booklet Distributed by the healthcare plan to its members, the booklet usually contains detailed information regarding the plan s policies, benefits, and procedures for appealing denial of insurance coverage. Prior authorization A request for prior authorization is required by most healthcare plans if a patient wishes to obtain insurance coverage for an elective surgery. The process involves either verbal or written communication between physician or his or her staff and the payer regarding the type of procedure to be performed, the rationale for surgery, the patient s history, and clinical documentation regarding the success of the surgery. In the case of Bariatric Surgery, a letter requesting prior authorization must be supplied to the insurer. School-to-school / Peer-to-Peer review In this type of review, an insurer hires a physician as a consultant to evaluate an appeal. The physician generally works in the same specialty as the treating physician, performs identical types of procedures, and has experience treating other patients with the same condition. Therefore, he or she is especially qualified to review the case. [15] [16]

10 DISCLAIMER AND EXCLUSION OF LIABILITY The information contained in this booklet is intended to be a general guideline only. Insurance requirements and procedures vary among insurers, whether public or private, and are subject to change. Covidien expressly disclaims any express or implied warranty that the information contained in this booklet is current, accurate or complete, or that adherence to the suggestions or other guidance contained in this booklet will result in a favorable coverage or reimbursement decision or comply with all reimbursement procedures or requirements of any particular health care reimbursement program or policy. In addition, Covidien expressly disclaims any express or implied warranty of merchantability, fitness of a particular purpose and non-infringement of intellectual property with respect to this booklet and the information it contains. Covidien does not assume liability, and under no circumstances shall Covidien be liable, for any damages, cost or expense arising out of the use of the information contained in this booklet. [17] [18]

11 COVIDIEN, COVIDIEN with Logo and marked brands are trademarks of Covidien AG or its affiliate Covidien AG or its affiliate. All rights reserved SS 1M 6.08 CBK00060M 150 Glover Avenue Norwalk, CT [t]

ifuse Implant System Patient Appeal Guide

ifuse Implant System Patient Appeal Guide ifuse Implant System Patient Appeal Guide Table of Contents PURPOSE OF THIS BOOKLET...................................................... 2 GUIDE TO THE APPEALS PROCESS..................................................

More information

A Consumer s Guide to Appealing Health Insurance Denials

A Consumer s Guide to Appealing Health Insurance Denials STATE OF CONNECTICUT Insurance Department Appeals & External Review Guide RIGHTS GUIDANCE APPEAL ASSISTANCE October 2013 A Consumer s Guide to Appealing Health Insurance Denials Introduction This guide

More information

A PATIENT S GUIDE TO. Navigating the Insurance Appeals Process

A PATIENT S GUIDE TO. Navigating the Insurance Appeals Process A PATIENT S GUIDE TO Navigating the Insurance Appeals Process Dealing with an injury or illness is a stressful time for any patient as well as for their family members. This publication has been created

More information

A Consumer s Guide to Appealing Health Insurance Denials

A Consumer s Guide to Appealing Health Insurance Denials STATE OF CONNECTICUT Insurance Department Appeals & External Review Guide RIGHTS GUIDANCE APPEAL ASSISTANCE October 2013 A Consumer s Guide to Appealing Health Insurance Denials Introduction How do I appeal

More information

Zimmer Payer Coverage Approval Process Guide

Zimmer Payer Coverage Approval Process Guide Zimmer Payer Coverage Approval Process Guide Market Access You ve Got Questions. We ve Got Answers. INSURANCE VERIFICATION PROCESS ELIGIBILITY AND BENEFITS VERIFICATION Understanding and verifying a patient

More information

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below.

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below. Tennessee Applicable Policies PRECERTIFICATION Benefits payable for Hospital Inpatient Confinement Charges and confinement charges for services provided in an inpatient confinement facility will be reduced

More information

Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers

Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers Table of Contents Introduction... 5 Prior Authorization... 7 Overview... 7 Step Therapy... 7 Quantity Limits... 7 The Prior Authorization

More information

005. Independent Review Organization External Review Annual Report Form

005. Independent Review Organization External Review Annual Report Form Title 210 NEBRASKA DEPARTMENT OF INSURANCE Chapter 87 HEALTH CARRIER EXTERNAL REVIEW 001. Authority This regulation is adopted by the director pursuant to the authority in Neb. Rev. Stat. 44-1305 (1)(c),

More information

Sample Appeal Letters

Sample Appeal Letters Sample Appeal Letters Appeals Payers who deny coverage usually do so for one of these three reasons: The therapy is investigational / experimental The therapy is not medically necessary The therapy is

More information

Unlisted Procedure Codes Frequently Asked Questions

Unlisted Procedure Codes Frequently Asked Questions Unlisted Procedure Codes Frequently Asked Questions Use of an unlisted code is common when a physician performs a new procedure or utilizes new technology when no other CPT code adequately describes the

More information

Patient Assistance Resource Center Health Insurance Appeal Guide 03/14

Patient Assistance Resource Center Health Insurance Appeal Guide 03/14 Health Insurance Appeal Guide 03/14 Filing a Health Insurance Appeal Use this reference guide to understand the health insurance appeal process, and the steps to take to have a health plan reconsider its

More information

EIMBURSEMENT. How to Write an Effective Appeal Provider Version

EIMBURSEMENT. How to Write an Effective Appeal Provider Version EIMBURSEMENT How to Write an Effective Appeal Provider Version INTRODUCTION At LDR, we understand the changing healthcare environment and how that impacts reimbursement. As the U.S. healthcare system becomes

More information

HEALTH INSURANCE APPEALS

HEALTH INSURANCE APPEALS Your Guide to filing HEALTH INSURANCE APPEALS Sometimes a health plan will make a decision that you disagree with. The plan may deny your application for coverage, determine that the healthcare services

More information

The Pennsylvania Insurance Department s. Your Guide to filing HEALTH INSURANCE APPEALS

The Pennsylvania Insurance Department s. Your Guide to filing HEALTH INSURANCE APPEALS Your Guide to filing HEALTH INSURANCE APPEALS Sometimes a health plan will make a decision that you disagree with. The plan may deny your application for coverage, determine that the healthcare services

More information

CALIFORNIA: A CONSUMER S STEP-BY-STEP GUIDE TO NAVIGATING THE INSURANCE APPEALS PROCESS

CALIFORNIA: A CONSUMER S STEP-BY-STEP GUIDE TO NAVIGATING THE INSURANCE APPEALS PROCESS Loyola Law School Public Interest Law Center 800 S. Figueroa Street, Suite 1120 Los Angeles, CA 90017 Direct Line: 866-THE-CLRC (866-843-2572) Fax: 213-736-1428 TDD: 213-736-8310 E-mail: CLRC@LLS.edu www.cancerlegalresourcecenter.org

More information

HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER

HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER CONSUMER'SGUIDE A Consumer s Guide to HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER from your North Carolina Department of Insurance A MESSAGE

More information

Getting the Medications and Treatments You Need

Getting the Medications and Treatments You Need Neuropathy Action Foundation Awareness Education Empowerment Getting the Medications and Treatments You Need Understanding Your Rights in Arizona As you search for a health insurance plan or coverage for

More information

Guide to Appeals. 30 Winter Street, Suite 1004, Boston, MA 02108 Phone +1 617-338-5241 Fax +1 617-338-5242 www.healthlawadvocates.

Guide to Appeals. 30 Winter Street, Suite 1004, Boston, MA 02108 Phone +1 617-338-5241 Fax +1 617-338-5242 www.healthlawadvocates. Guide to Appeals 30 Winter Street, Suite 1004, Boston, MA 02108 Phone +1 617-338-5241 Fax +1 617-338-5242 www.healthlawadvocates.org This guide was made possible by funding from the Commonwealth Health

More information

Phone: (888) 399-4925 Fax: (866) 866-4394 www.appealsolutions.com www.appeallettersonline.com. All Rights Reserved.

Phone: (888) 399-4925 Fax: (866) 866-4394 www.appealsolutions.com www.appeallettersonline.com. All Rights Reserved. Copyright protection claimed includes all letters and materials within. Reproduction of this material is expressly prohibited except as needed for internal purposes. Any subsequent distribution of copies,

More information

Appendix A Denial Management and Negotiation Hearing Screening

Appendix A Denial Management and Negotiation Hearing Screening Appendix A Denial Management and Negotiation Hearing Screening Ideally, hearing screenings should be covered benefits that are separately payable by the health plan. While health plan benefits may include

More information

(2) CMS 377 - Request to Establish Eligibility, found online at: http://www.cms.hhs.gov/cmsforms/downloads/cms377.pdf

(2) CMS 377 - Request to Establish Eligibility, found online at: http://www.cms.hhs.gov/cmsforms/downloads/cms377.pdf Health Care Regulation and Quality Improvement 800 NE Oregon Street, Suite 305 Portland, Oregon 97232 971-673-0540 971-673-0556 (Fax) This letter is in response to your expression of interest in becoming

More information

Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols

Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols 200 Old Country Road, Suite 470 Mineola, NY 11501 Phone: 516-294-4118 Fax: 516-294-9268 www.businessdynamicslimited.com

More information

Blue Care Network Physical & Occupational Therapy Utilization Management Guide Published 11/13/2012

Blue Care Network Physical & Occupational Therapy Utilization Management Guide Published 11/13/2012 Blue Care Network Physical & Occupational Therapy Utilization Management Guide Published 11/13/2012 Landmark Healthcare, Inc., oversees outpatient physical, occupational and speech services for BCN members

More information

What Happens When Your Health Insurance Carrier Says NO

What Happens When Your Health Insurance Carrier Says NO * What Happens When Your Health Insurance Carrier Says NO Most health carriers today carefully evaluate requests to see a specialist or have certain medical procedures performed. A medical professional

More information

UNIFORM HEALTH CARRIER EXTERNAL REVIEW MODEL ACT

UNIFORM HEALTH CARRIER EXTERNAL REVIEW MODEL ACT Model Regulation Service April 2010 UNIFORM HEALTH CARRIER EXTERNAL REVIEW MODEL ACT Table of Contents Section 1. Title Section 2. Purpose and Intent Section 3. Definitions Section 4. Applicability and

More information

A Consumer s Guide to Internal Appeals and External Reviews

A Consumer s Guide to Internal Appeals and External Reviews A Consumer s Guide to Internal Appeals and External Reviews The Iowa Insurance Division, Consumer Advocate Bureau http://www.insuranceca.iowa.gov June 2012 Table of Contents Introduction Page 3 Chapter

More information

External Review Request Form

External Review Request Form External Review Request Form This EXTERNAL REVIEW REQUEST FORM must be filed with the Nebraska Department of Insurance within FOUR (4) MONTHS after receipt from your insurer of a denial of payment on a

More information

VI. Appeals, Complaints & Grievances

VI. Appeals, Complaints & Grievances A. Definition of Terms In compliance with State requirements, ValueOptions defines the following terms related to Enrollee or Provider concerns with the NorthSTAR program: Administrative Denial: A denial

More information

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI)

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) The American Society for Gastrointestinal Endoscopy PIVI on Endoscopic Bariatric Procedures (short form) Please see related White

More information

(d) Concurrent review means utilization review conducted during an inpatient stay.

(d) Concurrent review means utilization review conducted during an inpatient stay. 9792.6. Utilization Review Standards Definitions For Utilization Review Decisions Issued Prior to July 1, 2013 for Injuries Occurring Prior to January 1, 2013. As used in this Article: The following definitions

More information

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS

More information

Comprehensive Health Insurance Billing Coding Reimbursement

Comprehensive Health Insurance Billing Coding Reimbursement Comprehensive Health Insurance Billing Coding Reimbursement SECOND EDITION CHAPTER 17 Refunds, Follow-up, and Appeals Key Terms and Abbreviations administrative law judge (ALJ) hearing documentation Employee

More information

How to Request an Exception or Appeal a Decision From Your Prescription Drug Plan

How to Request an Exception or Appeal a Decision From Your Prescription Drug Plan How to Request an Exception or Appeal a Decision From Your Prescription Drug Plan Exceptions What is an Exception? Sometimes you may not be able to obtain a prescription medication that your healthcare

More information

Bariatric Surgery. Required forms: (Forms are located at OHCA Forms ) Certification Criteria for Providers. Treatment for Obesity

Bariatric Surgery. Required forms: (Forms are located at OHCA Forms ) Certification Criteria for Providers. Treatment for Obesity Bariatric Surgery Required forms: (Forms are located at OHCA Forms ) HCA-13A HCA-12A Certification Criteria for Providers To be eligible for reimbursement, bariatric surgery providers must be certified

More information

Aetna Life Insurance Company Hartford, Connecticut 06156

Aetna Life Insurance Company Hartford, Connecticut 06156 Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment Policyholder: Group Policy No.: Effective Date: University Of Pennsylvania Postdoctoral Insurance Plan GP-861472 This Amendment is effective

More information

Medicare Appeals: Part D Drug Denials. December 16, 2014

Medicare Appeals: Part D Drug Denials. December 16, 2014 Medicare Appeals: Part D Drug Denials December 16, 2014 2013 Appeals Statistics by Type 23,716 Part D Reconsideration Appeals* Appeals Type Percentage of Total Appeals Appeals Per Million Medicare Beneficiaries

More information

Regulatory Compliance Policy No. COMP-RCC 4.20 Title:

Regulatory Compliance Policy No. COMP-RCC 4.20 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.20 Page: 1 of 11 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

Biodesign ADVANCED TISSUE REPAIR

Biodesign ADVANCED TISSUE REPAIR Biodesign ADVANCED TISSUE REPAIR 2013 CODING AND REIMBURSEMENT GUIDE FOR RECTOVAGINAL FISTULA The information provided herein reflects Cook Medical's understanding of the procedure(s) and/or devices(s)

More information

A Member s Guide to Long Term Disability LTD

A Member s Guide to Long Term Disability LTD A Member s Guide to Long Term Disability LTD Elementary Teachers Federation of Ontario January 2012 Long Term Disability Whatever entitlement to benefits you have is based on the language of the Long Term

More information

NEW YORK STATE EXTERNAL APPEAL

NEW YORK STATE EXTERNAL APPEAL NEW YORK STATE EXTERNAL APPEAL You have the right to appeal to the Department of Financial Services (DFS) when your insurer or HMO denies health care services as not medically necessary, experimental/investigational

More information

Aetna Life Insurance Company Hartford, Connecticut 06156

Aetna Life Insurance Company Hartford, Connecticut 06156 Aetna Life Insurance Company Hartford, Connecticut 06156 Amendment (GR-9N-Appeals 01-01 01) Policyholder The TLC Companies Group Policy No. GP-811431 Rider Arizona Complaint and Appeals Health Rider Issue

More information

Optimum Performance Physical Therapy, LLC

Optimum Performance Physical Therapy, LLC Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Email: Employer Name/ Address: Referring Physician: (P)

More information

Provider Appeals and Billing Disputes

Provider Appeals and Billing Disputes Provider Appeals and Billing Disputes UniCare Billing Dispute Internal Review Process A claim appeal is a formal written request from a physician or provider for reconsideration of a claim already processed

More information

MEDICAL COVERAGE POLICY. SERVICE: Bariatric (Weight Loss) Surgery Policy Number: 053 Effective Date: 5/27/2014 Last Review: 4/24/2014

MEDICAL COVERAGE POLICY. SERVICE: Bariatric (Weight Loss) Surgery Policy Number: 053 Effective Date: 5/27/2014 Last Review: 4/24/2014 Page 1 of 6 MEDICAL COVERAGE POLICY Important note Even though this policy may indicate that a particular service or supply is considered covered, this conclusion is not necessarily based upon the terms

More information

Maximizing Coverage Under the New Jersey Autism & Other Developmental Disabilities Insurance Mandate: A Guide for Parents and Professionals

Maximizing Coverage Under the New Jersey Autism & Other Developmental Disabilities Insurance Mandate: A Guide for Parents and Professionals Maximizing Coverage Under the New Jersey Autism & Other Developmental Disabilities Insurance Mandate: A Guide for Parents and Professionals About Autism New Jersey Autism New Jersey is the state s leading

More information

Premera Blue Cross Medicare Advantage Provider Reference Manual

Premera Blue Cross Medicare Advantage Provider Reference Manual Premera Blue Cross Medicare Advantage Provider Reference Manual Introduction to Premera Blue Cross Medicare Advantage Plans Premera Blue Cross offers Medicare Advantage (MA) plans in King, Pierce, Snohomish,

More information

Section Eleven. Referrals and Pre-Authorization REFERRAL PROCESS

Section Eleven. Referrals and Pre-Authorization REFERRAL PROCESS REFERRAL PROCESS Physician Referrals within Plan Network Physicians may refer members to any Specialty Care Physician (Specialist) or ancillary provider within the Fidelis Care network. Except as noted

More information

ICD-10 and Its Impact on the Healthcare Industry

ICD-10 and Its Impact on the Healthcare Industry Point of View ICD-10 and Its on the Healthcare Industry Written by Stacy Swartz, RHIA, CCS, CPC Vice President of Coding for Sutherland Healthcare Solutions On January 16, 2009, the U.S. Department of

More information

Health Care Management Policy and Procedure

Health Care Management Policy and Procedure Utilization Management... 2 Pharmaceutical Management... 3 Member Clinical Appeal and Independent External Review ASO Groups Not Voluntarily Complying with the Illinois External Review Act (Federal)...

More information

New Jersey Regional Claims PO Box 5483 Mount Laurel, NJ 08054 Phone : 1-800-451-5982 Fax : 856-235-6232. Date (##/##/####)

New Jersey Regional Claims PO Box 5483 Mount Laurel, NJ 08054 Phone : 1-800-451-5982 Fax : 856-235-6232. Date (##/##/####) New Jersey Regional Claims PO Box 5483 Mount Laurel, NJ 08054 Phone : 1-800-451-5982 Fax : 856-235-6232 Date (##/##/####) Physician Name Street Address City, State, Zip Claimant: Claim Number: Medlogix

More information

FAQs Regarding Insurance Funding for Behavioral Health Treatment for Autism and PDD September 28, 2012

FAQs Regarding Insurance Funding for Behavioral Health Treatment for Autism and PDD September 28, 2012 FAQs Regarding Insurance Funding for Behavioral Health Treatment for Autism and PDD September 28, 2012 Please note that this document provides information about a situation that continues to evolve. As

More information

4/11/14. Medical Director, Bariatric Surgery Mountainview Regional Medical Center. ! None. ! Discuss the ongoing epidemic of obesity

4/11/14. Medical Director, Bariatric Surgery Mountainview Regional Medical Center. ! None. ! Discuss the ongoing epidemic of obesity Medical Director, Bariatric Surgery Mountainview Regional Medical Center! None! Discuss the ongoing epidemic of obesity! Discuss current treatment options! Discuss the role of bariatric surgery! Review

More information

Dear Sir/Madam: Thank you for this opportunity to be of service, and please do not hesitate to contact our claims center if you have any questions.

Dear Sir/Madam: Thank you for this opportunity to be of service, and please do not hesitate to contact our claims center if you have any questions. Dear Sir/Madam: Kindly be advised that National Adjustment Bureau has been authorized by underwriters to adjudicate your claim. We look forward to resolving your claim in a prompt and equitable manner.

More information

SECTION 4. A. Balance Billing Policies. B. Claim Form

SECTION 4. A. Balance Billing Policies. B. Claim Form SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing

More information

TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS

TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS ADMINISTRATIVE POLICY TIMEFRAME STANDARDS FOR UTILIZATION MANAGEMENT (UM) INITIAL DECISIONS Policy Number: ADMINISTRATIVE 088.15 T0 Effective Date: November 1, 2015 Table of Contents APPLICABLE LINES OF

More information

Welcome to American Specialty Health Insurance Company

Welcome to American Specialty Health Insurance Company CA PPO Welcome to American Specialty Health Insurance Company American Specialty Health Insurance Company (ASH Insurance) is committed to promoting high quality insurance coverage for complementary health

More information

9. Claims and Appeals Procedure

9. Claims and Appeals Procedure 9. Claims and Appeals Procedure Complaints, Expedited Appeals and Grievances Under Empire s Hospital Benefits or Retiree Health Benefits Plan Complaints If Empire denies a claim, wholly or partly, you

More information

istent Trabecular Micro-Bypass Stent Reimbursement Guide

istent Trabecular Micro-Bypass Stent Reimbursement Guide istent Trabecular Micro-Bypass Stent Reimbursement Guide Table of Contents Overview Coding 3 4 Coding Overview Procedure Coding Device Coding Additional Coding Information Coverage Payment 10 11 Payment

More information

CARE PATHS/DECISION POINT REVIEW

CARE PATHS/DECISION POINT REVIEW Personal Service Insurance Company PO Box 3001 Plymouth Meeting, PA 19462 Ph: 610.832.4940 Fax: 610.832.2138 Toll Free: 800.954.2442 Date (##/##/####) Physician Name Street Address City, State, Zip Claimant:

More information

OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT

OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT OFFICE OF GROUP BENEFITS 2014 OFFICE OF GROUP BENEFITS CDHP PLAN FOR STATE OF LOUISIANA EMPLOYEES AND RETIREES PLAN AMENDMENT This Amendment is issued by the Plan Administrator for the Plan documents listed

More information

Early Intervention Central Billing Office. Provider Insurance Billing Procedures

Early Intervention Central Billing Office. Provider Insurance Billing Procedures Early Intervention Central Billing Office Provider Insurance Billing Procedures May 2013 Provider Insurance Billing Procedures Provider Registration Each provider choosing to opt out of billing for one,

More information

Making it happen HOW TO ACCESS BEHAVIORAL HEALTH TREATMENT SERVICES FROM PRIVATE HEALTH INSURANCE FOR INDIVIDUALS WITH AUTISM A GUIDE FOR PARENTS

Making it happen HOW TO ACCESS BEHAVIORAL HEALTH TREATMENT SERVICES FROM PRIVATE HEALTH INSURANCE FOR INDIVIDUALS WITH AUTISM A GUIDE FOR PARENTS Making it happen HOW TO ACCESS BEHAVIORAL HEALTH TREATMENT SERVICES FROM PRIVATE HEALTH INSURANCE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS A GUIDE FOR PARENTS SECTION 1 SECTION 2 SECTION 3 SECTION

More information

HIRING A QUALIFIED OFFICE STAFF

HIRING A QUALIFIED OFFICE STAFF Tinsley, Reed. Streamlining Medical Practice Reimbursements. Career Pulse December 1994: 38-41. Streamlining Medical Practice Reimbursements Physicians must actively manage their medical practices for

More information

The CPT Approval Process

The CPT Approval Process The CPT Approval Process CPT is an acronym for Current Procedural Terminology (CPT ). CPT codes are published by the American Medical Association (AMA). A CPT code is a five digit numeric code that describes

More information

Your DuPont Benefit Resources. Total and Permanent Disability Income Plan July 2008

Your DuPont Benefit Resources. Total and Permanent Disability Income Plan July 2008 Your DuPont Benefit Resources Total and Permanent Disability Income Plan July 2008 TABLE OF CONTENTS DETAILS OF THE PLAN...1 PREFACE...1 INTRODUCTION...1 ELIGIBILITY...1 ENROLLMENT...2 COST...2 PLAN BENEFIT...2

More information

CHAPTER 17 CREDIT AND COLLECTION

CHAPTER 17 CREDIT AND COLLECTION CHAPTER 17 CREDIT AND COLLECTION 17101. Credit and Collection Section 17102. Purpose 17103. Policy 17104. Procedures NOTE: Rule making authority cited for the formulation of regulations for the Credit

More information

HOW TO APPEAL A MEDICAL ASSISTANCE DENIAL OF ASSISTIVE TECHNOLOGY

HOW TO APPEAL A MEDICAL ASSISTANCE DENIAL OF ASSISTIVE TECHNOLOGY HOW TO APPEAL A MEDICAL ASSISTANCE DENIAL OF ASSISTIVE TECHNOLOGY Figure 1: Doctor s prescription. Prepared by: Disability Rights Network of Pennsylvania www.drnpa.org 1-800-692-7443 [Voice] 1-877-375-7139

More information

SUBCHAPTER R. UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY 28 TAC 19.1701 19.

SUBCHAPTER R. UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY 28 TAC 19.1701 19. Part I. Texas Department of Insurance Page 1 of 244 SUBCHAPTER R. UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY 28 TAC 19.1701 19.1719 SUBCHAPTER U.

More information

MEDICAL MANAGEMENT OVERVIEW MEDICAL NECESSITY CRITERIA RESPONSIBILITY FOR UTILIZATION REVIEWS MEDICAL DIRECTOR AVAILABILITY

MEDICAL MANAGEMENT OVERVIEW MEDICAL NECESSITY CRITERIA RESPONSIBILITY FOR UTILIZATION REVIEWS MEDICAL DIRECTOR AVAILABILITY 4 MEDICAL MANAGEMENT OVERVIEW Our medical management philosophy and approach focus on providing both high quality and cost-effective healthcare services to our members. Our Medical Management Department

More information

istent Trabecular Micro-Bypass Stent Reimbursement Guide

istent Trabecular Micro-Bypass Stent Reimbursement Guide istent Trabecular Micro-Bypass Stent Reimbursement Guide Table of Contents Overview Coding 2 3 Coding Overview Procedure Coding Device Coding Additional Coding Information Coverage Payment 8 9 Payment

More information

THE ALMOST HASSLE-FREE WAY TO COLLECT PA WORKERS COMPENSATION MEDICAL BILLS

THE ALMOST HASSLE-FREE WAY TO COLLECT PA WORKERS COMPENSATION MEDICAL BILLS www.workinjuryinpa.com THE ALMOST HASSLE-FREE WAY TO COLLECT PA WORKERS COMPENSATION MEDICAL BILLS This book has the forms and guidance to get your workers compensation medical bills paid. THE ALMOST HASSLE-FREE

More information

LEGISLATURE OF THE STATE OF IDAHO Sixtieth Legislature First Regular Session 2009 IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO.

LEGISLATURE OF THE STATE OF IDAHO Sixtieth Legislature First Regular Session 2009 IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO. LEGISLATURE OF THE STATE OF IDAHO Sixtieth Legislature First Regular Session 0 IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO. BY BUSINESS COMMITTEE 0 AN ACT RELATING TO HEALTH INSURANCE; AMENDING TITLE,

More information

Health Insurance in Ohio

Health Insurance in Ohio Cancer Legal Resource Center 919 Albany Street Los Angeles, CA 90015 Toll Free: 866.THE.CLRC (866.843.2572) Phone: 213.736.1455 TDD: 213.736.8310 Fax: 213.736.1428 Email: CLRC@LLS.edu Web: www.cancerlegalresourcecenter.org

More information

Clinical Policy Guideline

Clinical Policy Guideline Clinical Policy Guideline Policy Title: Obesity Medical/Surgical Management Effective Date: 07/13/2004 Date Reviewed: 06/18/2011, 12/15/2011, 02/22/2012, 06/26/2012, 07/16/2012, 01/23/2013, 11/26/2014,

More information

Title 19, Part 3, Chapter 14: Managed Care Plan Network Adequacy. Requirements for Health Carriers and Participating Providers

Title 19, Part 3, Chapter 14: Managed Care Plan Network Adequacy. Requirements for Health Carriers and Participating Providers Title 19, Part 3, Chapter 14: Managed Care Plan Network Adequacy Table of Contents Rule 14.01. Rule 14.02. Rule 14.03. Rule 14.04. Rule 14.05. Rule 14.06. Rule 14.07. Rule 14.08. Rule 14.09. Rule 14.10.

More information

California Provider Reference Manual Introduction and Overview of Medical Provider Networks (CA MPNs)

California Provider Reference Manual Introduction and Overview of Medical Provider Networks (CA MPNs) California Provider Reference Manual Introduction and Overview of Medical Provider Networks (CA MPNs) Coventry/First Health has designed this manual for The Coventry/First Health Network providers participating

More information

Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan

Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan ConneCtiCut insurance DePARtMent Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral

More information

What s fair? Fair healthcare pricing from Healthcare Blue Book

What s fair? Fair healthcare pricing from Healthcare Blue Book What s fair? Fair healthcare pricing from Healthcare Blue Book Healthcare Blue Book is a free consumer guide to help you determine fair prices in your area healthcare services Lap-Band (CPT code 43770)

More information

Regulatory Compliance Policy No. COMP-RCC 4.25 Title:

Regulatory Compliance Policy No. COMP-RCC 4.25 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 1 of 16 Effective Date: 03-19-15 Retires

More information

407-767-8554 Fax 407-767-9121

407-767-8554 Fax 407-767-9121 Florida Consumers Notice of Rights Health Insurance, F.S.C.A.I, F.S.C.A.I., FL 32832, FL 32703 Introduction The Office of the Insurance Consumer Advocate has created this guide to inform consumers of some

More information

BlueAdvantage SM Health Management

BlueAdvantage SM Health Management BlueAdvantage SM Health Management BlueAdvantage member benefits include access to a comprehensive health management program designed to encompass total health needs and promote access to individualized,

More information

XXXXX Petitioner File No. 113467-001 v. Issued and entered this _12th_ day of October 2010 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND

XXXXX Petitioner File No. 113467-001 v. Issued and entered this _12th_ day of October 2010 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND In the matter of STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation XXXXX Petitioner

More information

Medicaid-Designated NYC Hospitals for Bariatric Surgery for Obesity ------------------------------------------ QUESTIONS AND ANSWERS

Medicaid-Designated NYC Hospitals for Bariatric Surgery for Obesity ------------------------------------------ QUESTIONS AND ANSWERS Medicaid-Designated NYC Hospitals for Bariatric Surgery for Obesity ------------------------------------------ QUESTIONS AND ANSWERS RFA Number 0810300900 All questions are stated as received by the deadline

More information

University Healthcare Administrative Policy

University Healthcare Administrative Policy Page 1 of 6 APPROVED BY: Signatures on File FINANCIAL POLICY (UH) is a not-for profit teaching hospital committed to providing quality health care services. In order to provide necessary medical services

More information

Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C

Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT This agreement describes your benefits from Blue Cross & Blue Shield of Rhode Island. This is a Medicare

More information

AGENCY FOR HEALTH CARE ADMINISTRATION HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE 2727 Mahan Drive Tallahassee Florida 32308

AGENCY FOR HEALTH CARE ADMINISTRATION HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE 2727 Mahan Drive Tallahassee Florida 32308 AGENCY FOR HEALTH CARE ADMINISTRATION HEALTH QUALITY ASSURANCE BUREAU OF MANAGED HEALTH CARE 2727 Mahan Drive Tallahassee Florida 32308 WORKERS COMPENSATION MANAGED CARE ARRANGEMENT SURVEY REPORT NAME

More information

Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan

Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan CONNECTICUT INSURANCE DEPARTMENT Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral

More information

Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS)

Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS) Final National Health Care Billing Audit Guidelines as amended by The American Association of Medical Audit Specialists (AAMAS) May 1, 2009 Preface Billing audits serve as a check and balance to help ensure

More information

Frequently Asked Network Questions

Frequently Asked Network Questions Frequently Asked Network Questions Press CTRL and click on the question to jump to a specific question New and revised questions from the previous version are noted in italics General Questions...3 1.

More information

Texas June 2005. The following elements are particularly important in shaping our plans to support this new legislation:

Texas June 2005. The following elements are particularly important in shaping our plans to support this new legislation: Texas June 2005 On June 1, 2005, Texas Governor Rick Perry signed House Bill 7 (HB 7) into law. First Health believes this new legislation is a major step in controlling Workers Compensation expenses.

More information

FREQUENTLY ASKED QUESTIONS

FREQUENTLY ASKED QUESTIONS FREQUENTLY ASKED QUESTIONS The American Academy of Dental Sleep Medicine provides support for its members in matters relating to insurance reimbursement for oral appliance therapy. The following section

More information

How to Prepare a Winning RAC Appeal

How to Prepare a Winning RAC Appeal How to Prepare a Winning RAC Appeal Craneware InSight Consulting Copyright 2011, CRANEWARE INSIGHT. All rights reserved. www.cranewareinsight.com p.1 Introduction Introductions Karen Bowden, RHIA, Senior

More information

Insurance Intake Form, Authorization and Assignment of Benefits

Insurance Intake Form, Authorization and Assignment of Benefits Recipient Information Insurance Intake Form, Authorization and Assignment of Benefits Return completed and signed form with copies of insurance card(s), front and back, to: Fax: (303) 200-5441 E-mail:

More information

Coding for same-day visits and procedures By Emily Hill, PA-C

Coding for same-day visits and procedures By Emily Hill, PA-C Coding for same-day visits and procedures By Emily Hill, PA-C Can you get insurers to pay you for a procedure like endometrial biopsy performed at the same time as a problem-oriented visit? Sometimes.

More information

California Workers Compensation Medical Provider Network Employee Notification & Guide

California Workers Compensation Medical Provider Network Employee Notification & Guide California Workers Compensation Medical Provider Network Employee Notification & Guide In partnership with We are pleased to introduce the California workers compensation medical provider network (MPN)

More information

A BILL FOR AN ACT ENTITLED: "AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR

A BILL FOR AN ACT ENTITLED: AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR HOUSE BILL NO. INTRODUCED BY G. MACLAREN BY REQUEST OF THE STATE AUDITOR 0 A BILL FOR AN ACT ENTITLED: "AN ACT ADOPTING AND REVISING PROCESSES THAT PROVIDE FOR UTILIZATION REVIEW, GRIEVANCE, AND EXTERNAL

More information

geographical service area and the employee did not voluntarily agree to participate in network, then there is no requirement to see a network doctor.

geographical service area and the employee did not voluntarily agree to participate in network, then there is no requirement to see a network doctor. WC NETWORK FREQUENTLY ASKED QUESTIONS (FAQ) What is the network? A Workers Compensation network is an organization formed as a healthcare provider network certified by the Texas Department of Insurance

More information

INDIANA: Frequently Asked Questions About the Autism Insurance Reform Law. What does Indiana s Autism Spectrum Disorder Insurance Mandate do?

INDIANA: Frequently Asked Questions About the Autism Insurance Reform Law. What does Indiana s Autism Spectrum Disorder Insurance Mandate do? INDIANA: Frequently Asked Questions About the Autism Insurance Reform Law What does Indiana s Autism Spectrum Disorder Insurance Mandate do? Broadly speaking, the insurance mandate requires insurance providers

More information

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider. Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best

More information