Good Afternoon Denise: Appeal Or Reprocess For Payment?

The evidence in file shows the claimant has a history of advanced COPD requiring oxygen (O2) and moderate obesity with a BMI as high as 36. At an office visit on 12/11/14 the claimant’s O2 saturation level was 95% and down to 88% with exercise on RA. The physical exam on 2/10/15 shows 93% oxygen saturation. The lungs were clear to auscultation. At the exam on 5/14/14 the claimant had intentionally lost 25 pounds. She was

I had robotic hysterectomy on 12/16/2016 and around 12/23/2016 I called Penfed and spoke with executive regarding the disability to fill the claim. The executive explains to me that its crucial to make the first payment. That they will filled the claim to Minnesota Life, and if Minnesota Life denies the claim we could do a skipped payment. Well I called Yesterday a Young Dan which is a supervisor says its impossible sees the notes and sees that the person I was

If you are unsatisfied with this decision, then you have the right to appeal. This appeal should again be made in writing, and your employer must arrange another meeting.

Rather than having the other claims adjusted, the provider insisted that we not look into the matter further because they did not want us to take back any money. Sadly this is just one example of fraud; it is not uncommon to see providers change the coding of claims to get something that they know should not be paid to process for payment. Cracking down on this type of fraud will reduce the amount of money paid out on claims by insurance carriers. Since claims payments directly affect the cost of insurance, this will also help in lowering premiums.

The provider had an authorization on file approving the dental services advising that they were medically necessary. But when the provider billed, they only advised the services were dental and not medical. Therefore causing the claim to deny. Also, provider didn’t reference their authorization number in box 63 of their claim form which would have voided the claim from denying. This claim will be sent back to be reprocessed. Please advise and ETA of 01/13.

On December 29, 2015, a beneficiary hearing was held at the request of Mr. Jeffery Williams. The hearing was requested to appeal the denial of Medicaid benefits due to an unfavorable disability decision.

The Appellant’s cash assistance appeal request was filed untimely. The regulation at 55 Pa. Code § 275.3(b) provides that the time limits for filing a cash assistance appeal is “thirty days from the date of written notice of a decision or action by a County Assistance Office, administering agency or service provider”.

Could you please assist me? My associate was reviewing appeal # APP-2018599 that was completed by Priscilla Wilkerson. She notice that all the claims checks were suppressed when they were not advised in the SOW to processed this way. In order for all 18 claims to be reprocessed, Danielle has been advised to redo the SOW. Since, this was not her error, I think that these claims need to be reprocessed again correctly by Priscilla or another claim analyst. Could you please review and advise? Attached is communication from Danielle trying to get assistance from Priscilla regarding the mistake that was made and Kishma advising of next steps.

The anomalous claim (DIB) filed on 08/03/2017. We obtained the necessary document form the NH on 09/15/17 and completed the subsequent requirements on 10/12/17. Please let me know

The carrier has denied coverage of continued occupational therapy from 07/29/2015 - forward as not medically necessary. There is a letter from the carrier to the member, dated 03/29/2016, which states in part:

The Appellant is appealing a decision of the Department to determine her ineligible for MA and only eligible for Buy-In of her Medicare Part B Premium payment.

The appeal is considered untimely because the notice denying the Appellant’s application for MA benefits was sent to her on May 5, 2016, and her Guardian’s request for an appeal was not received by the Department until September 14, 2016, one-hundred and three (103) days after the timeframe to appeal had expired. It is the Notice from the Department that

DI 23007.005G.2 indicates if attempts to receive information by mail is unsuccessful, DDS should contact the claimant by phone. “If you reach the claimant, collect the information requested over the phone. Thus, the prior determination was incorrect and a re-opening is warranted.

In your letter you claim that you submitted a Step II appeal on 01/15/2017, which was never received at Central Office. You were then allowed to resubmit your Step II Appeal and your time frames were reset. You state that to reset the timeframe is not in policy.

“The specific reason for this denial of your appeal for Harvoni is that the coverage guidelines had not been met