Appeal - UC 7: Perform medical review of an appeal
Pega Foundation for Healthcare
- Retrieve the case from MDReview@MyHealthPlan workbasket.
- System displays following Claim line information for each line in the claim:
- Service Date
- Procedure Code
- Charge Amount
- Payer paid amount
- Denial reason
The system also displays the Claim line information for reconsideration. The system ensures that information entered during Nurse review is available in MD review.
- Edit the “Patient paid amount” and denial reason to deny reconsideration.
- Edit Guideline/Policy reference used for reconsideration. The following
Guideline/Policy reference information can be edited:
- Policy Number
- Medical Policy Date
- Medical Policy name
- Guideline number
- Guideline name
- Page number
- Reviewer may decide to route appeal to any of the following workbaskets:
- RequestAdditionalInformation
- TransferToManager
- TransferToUM (Utilization Manager)
- TransferToMD (medical Director)
- TransferToCR (claims Review)
In case, reviewer routes the case to any of the above workbaskets then system mandates adding forwarding comment before case routing.
- Select disposition. By default, the system displays the Nurse Review’s disposition.
- Edit comments and click Submit to record MD Review’s
disposition.
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