- 1st level appeal- a request for an additional review of the decision to deny service. To meet 2005 URAC standards the appeal must be done by a physician who was not involved in the original denial.
- Peer-to-Peer Review- A request by the physician treating the patient, for a telephone review with the reviewer who denied the request.
- External Review- A review done by an independent review organization. External reviews are typically done after the insurance companies internal review process has been exhausted.
Denials are often due to lack of information to support approving the request. Better communication and documentation provided to the insurance company at the time of request, would decrease the number of denials and therefore the number of appeal. This in turn saves the case manager the time of going through the appeals process. It also saves the patient the stress believing their needed services will not be covered.
Coordination of Benefits (COB)
The primary plan is initially responsible for payment of benefits for covered services as if there was no other plan. After the primary has paid, the balance is passed to the secondary company which will pay according to their contract.
The following lists the order to determine which plan is primary:
- If an insurance plan does not have a COB provision that plan must pay primary.
- If none of the below apply the coverage that has been in force the longest is primary.
- The Insurance plan covering the client as employee pays primary, over the plan covering as a dependent which pays secondary.
- The insurance plan that covers an active employee is primary over the plan that covers a laid-off employee or retiree.
- The insurance plan that covers and active employee is primary over a COBRA plan which is secondary.
Dependents of Married Parents
The birthday rule states- if the parents are married, the parent whose birthday comes first in the year is primary for the children.
- If both plans cover the client as a dependent, and both plans have adopted the birthday rule, the birthday rule applies.
- If both plans cover the client as a dependent, neither plan has adopted the birthday rule, and the parents are married, the fathers plan pays first.
Dependents of Non-married Parents
- If both plans cover the client as a dependent and the parents are not married, primary coverage is determined by the court.
- If no court determination has been made, the parent with custody is primary, followed by the spouse of the parent with custody, and finally the plan of the parent without custody.
Medicare is very complicated and I recommend taking a look at the chart on pages 6 and 7 at Medicare.gov for better understanding. Below is a brief overview of the most common instances a Case Manager will encounter:
- Age 65 or older and retired, Medicare is primary
- Age 65 or older and covered due to patient or spouse working for employee with 20 or more employees, employer plan is primary.
- Age 65 or older and covered due to patient or spouse working for employee with less than 20 employees, Medicare is primary.