Description

Covers the UM 4-7 standards on denials including appropriate professionals, timeliness of decisions, clinical information, appropriate rationale, denial notices, and the importance of using member-friendly language in notifications. Identifies files included and excluded from review, insights from Policy Clarification Support (PCS) questions, and FAQs. Emphasizes Must-Pass Elements.

Learning Objectives:

• Describe the requirements for appropriate professionals who can make decisions on denials for medical necessity, experimental and investigational treatments, and benefits.
• Specify appropriate clinical documentation, including the rationale for making a denial decision.
• Recognize the importance of using member-friendly language in notifications and when revisions are necessary.
• Identify appropriate reasons and timeframes for extensions of denial decisions.
• Identify the required language for the appeals process needed in the denial notification.
• Identify files to be included and excluded in the denial file universe.

Length: 2 Hours

Price:

List Price for Non MHR Clients: $5,000

MHR Clients: [20% discount off List Price] $4,000