Appeals Process
Provider requests services authorization from health Plan
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Service approved by health plan ✅
Plan continues to deny service request in whole or in part ❌
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Service approved by health plan ✅
plan continues to deny service request in whole or in part ❌
Beneficiary requests state fair hearing
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Service approved by health plan ✅
plan continues to deny service request in whole or in part ❌
Lrem
Service approved by health plan ✅
service authorization denied ❌
Beneficiary requests state fair hearing
CONCEPT MAP BOXES
Clayton Blackwelder
Created on April 19, 2023
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Transcript
Appeals Process
Provider requests services authorization from health Plan
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Service approved by health plan ✅
Plan continues to deny service request in whole or in part ❌
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Service approved by health plan ✅
plan continues to deny service request in whole or in part ❌
Beneficiary requests state fair hearing
Appeals Process
Provider requests services authorization from health Plan
Service approved by health plan ✅
health plan denies request and sends notice of adverse benefit determination ❌
Beneficiary appeals decision through standard or expedited internal appeals process
Service approved by health plan ✅
plan continues to deny service request in whole or in part ❌
Lrem
Service approved by health plan ✅
service authorization denied ❌
Beneficiary requests state fair hearing