eNewsletter: Reimbursement eNewsletter for the healthcare community

ISSUE 53 Aug 11, 2008














Utilization Review Denials: Are Patients Abandoned or Offered Alternatives? Carriers have a responsibility to provide detailed responses to utilization review requests. Further, when adverse determinations are given, many consumer protections require the carrier’s written denials to explain the clinical criteria supporting the decisions and provide appeal information. Read how you can ensure your patients receive information on treatment alternatives available under the coverage terms. Read this entire article....
AppealLettersOnline Featured Letters
We have a number of appeal letters specifically designed for utilization review appeals. The following letters are located under the Topic: Medical Necessity and the Subcategory: URAC Standards:
1. Request for Peer-to-Peer Conversation
2. Lack of Timely Decision
3. Lack of Written Decision
4. Lack of Appeal Response
5. Records Request Response
6. Lack of One Day Response

For assistance with adapting these letters to your organization’s requirements, members should post their questions in the forum area specific for Medical Necessity.  Onsite Utilization Review Appeal Training is also available from Appeal Solutions.
Sign up to access these letters
Power of Appeals Makes the "Utilization Review Paper Trail" Easy to Control
Utilization review often starts and ends with a simple phone call.  However, it increasingly involves submission of written requests and clinical information to the carrier and tracking disposition of the request while patients await crucial carrier approvals.

Our Power of Appeals software makes appealing and tracking utilization review requests easy. The easy to use software features patient account tracking, built-in appeal letters and the ability to set accounts for follow-up on a specified time frame.  Users can configure their own utilization review requests and appeal letters within the software or use the software’s existing appeal letter database.  Fields are also available for tracking authorization numbers, insurance carrier information and days allowed and/or days denied. The software even has letters citing each state’s utilization review statutes regarding time frame for response and appeal review requirements.  A 20-minute online demo of Power of Appeals can be scheduled by calling Tammy Tipton at 888-399-4925 ext 703.