Skip to main content

         This documentation site is for previous versions. Visit our new documentation site for current releases.      

Appeal - UC 7: Perform medical review of an appeal

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

  2. 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.

  3. Edit the “Patient paid amount” and denial reason to deny reconsideration.
  4. 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
  5. 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.

  6. Select disposition. By default, the system displays the Nurse Review’s disposition.
  7. Edit comments and click Submit to record MD Review’s disposition.

  • Previous topic Appeal - UC 6: Clinical review of appeal information
  • Next topic Common - UC 8: Communicate appeals resolution

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Did you find this content helpful?

Want to help us improve this content?

We'd prefer it if you saw us at our best. is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us