Appeals for Inpatient Services an appeal for inpatient care (also referred to as length of stay) can be requested at multiple levels of service including prospective, concurrent, or retrospective. these types of appeals are a high category for provider appeals at anthem, as well. length of stay appeals represent 0.91 provider appeals per thousand members per year. A Prospective Appeal can be requested for non-covered inpatient services that have a planned (future) date of service. you may be required to get written authorization from the member to act as their authorized representative for a prospective appeal. A Concurrent Appeal can be requested for non-covered inpatient services that are in progress or ongoing (e.g. inpatient care). you may be required to get written authorization from the member to act as their authorized representative for a concurrent appeal. Please note that for concurrent reviews, utilization management will review services for which a coverage decision has not been made while grievances and appeals will review services for which a coverage decision has already been made. A Retrospective Appeal can be requested for non-covered inpatient services that have already been provided. you may ask for a retrospective appeal on your own behalf. you may be required to get written authorization from the member to act as their authorized representative for a retrospective appeal. to help us effectively process an appeal for an adverse coverage decision for inpatient services, please send us any pertinent medical information you have to support the request, regardless of whether it was considered at the time the initial decision was made, including (but not limited to) procedure notes, therapy notes, progress notes, history and physical, nursing notes, and adjunctive therapy notes (e.g., respiratory or physical therapy notes). Please also specifically identify what the appeal is being requested for. it is important for you to explain to the plan for each claim that you wish to appeal exactly why you feel the plan should reconsider your claim. giving a generic reason for the appeal will make it difficult for Wellpoint to respond timely and appropriately. Kimberly Stevens started her career with WellPoint in 2001 as a call center representative in Member Services. In 2002 she moved to the Grievances and Appeals Department as an appeals representative, handling member and provider appeals. She has remained dedicated to Grievances and Appeals since that time. Shortly after joining Grievances and Appeals, she became a process improvement consultant, continuously looking for ways to improve the appeals process for internal and external customers. From there she became a process improvement manager, a role she continues to be in today. As a process improvement manager, Kimberly is dedicated to risk management and process improvement for Grievances and Appeals for 14 states. SPECIAL VISIT TO THE HILL DAY JULY 17 FIVE MODULES ADDRESS CORE BUSINESS COMPETENCY Marketing Technology Legal/Operations Financial Management Strategic Planning JULY 18 - 20, 2013 WASHINGTON, DC the journal of the healthcare billing and management association 33
Billing_MJ13
To see the actual publication please follow the link above