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Appeal - UC 5: Review and research appeal information

Updated on January 31, 2022
Pega Foundation for Healthcare
  1. Retrieve the case from Research workbasket.

  2. Review following information:
    • Appeal Category
    • Appeal Reason
    • Service Type
    • Description (comments entered for Complaint reason while creating complaint)
    • True organization receipt date (Date on which Payer received the complete complaint details. SLA and deadlines are calculated with this date as a baseline).

  3. Edit urgency if required. If “Handled with urgency“ is selected as ‘Yes’ then case is handled with expedited urgency. System also updates the deadline of case based on urgency. SLA parameters are user-configured in either SetSLAForCMSCaseTypes, or SetSLAForCMSCaseTypes decision tables depending on the member’s Line of Business.
  4. Check if good cause* is required.

    *Good cause is required if the complaint is received after certain number of incident days. Many times, organizations do not entertain any complains after 90 days of incident. If member field complain after complaint filing deadline then a good cause is required.

  5. Check if waiver liability* is required.

    *If the complaint is filed by a non-contracted provider, organization may require waiver liability before working on complain resolution.

  6. System displays following Claims/Authorization information if any related to case.

    Claims or Authorization displayed are based on appeal reason and the appeal/ claim selected during complain creation.

    Claims informationAuthorization information
    Claims IDAuth ID
    Claim Type (Professional, Institutional, or Dental)Type of Service
    Received datePlace of Service
    Amount ChargedService Date
    Amount paid by memberAuthorization Status
    Principal Diagnosis code and code type
  7. Edit Claim ID/Authorization ID as required and add comment if required.
  8. Enter applicable medical policy and clinical guidelines information.
  9. User skips the administrative closure by selecting ‘No’ for “Administrative closure”**.

    **Research associate may decide appeal’s disposition and resolve the case. System allows the same by giving option of “Administrative closure”. If user selects ‘yes’ for administrative closure, then disposition section is displayed, and use can select appropriate disposition.

    System skips Nurse and MD review.

  10. User clicks Submit to move case to next stage.
  11. System updates “Actual organization receipt date” as the latest of Organization received date, AOR received date, Waiver liability received date and Good cause received date.
  12. System moves the case to NurseReview@MyHealthPlan workbasket for Nurse Review.
  • Previous topic Complaint - UC 4: Move case out of PendingAOR workbasket
  • Next topic Appeal - UC 6: Clinical review of appeal information

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