Podcast
Questions and Answers
In what situation is signed consent required to file an appeal?
In what situation is signed consent required to file an appeal?
- When appealing a denial of service.
- When the member is a minor.
- When anyone besides the member is appealing. (correct)
- When the appeal involves sensitive health information.
What is the key distinction to consider when handling a member's issue?
What is the key distinction to consider when handling a member's issue?
- The member's eligibility status.
- Whether the issue should be coded as a complaint or an appeal. (correct)
- Whether the member has previously filed a similar issue.
- The member's preferred language.
Under what condition should an expedited appeal be initiated?
Under what condition should an expedited appeal be initiated?
- If the member disagrees with a Molina decision.
- If the appeal involves prescription medication.
- If the member requests it in writing.
- If the caller explicitly states it is an urgent or expedited request. (correct)
What is the critical factor in determining if an individual is considered an enrollee for appeal and grievance rights?
What is the critical factor in determining if an individual is considered an enrollee for appeal and grievance rights?
A member's case involving disagreement with a Molina decision should be coded as:
A member's case involving disagreement with a Molina decision should be coded as:
What is the role of PHI authorization in the appeals process for someone other than the member?
What is the role of PHI authorization in the appeals process for someone other than the member?
Which of the following scenarios best describes someone entitled to appeal and grievance rights?
Which of the following scenarios best describes someone entitled to appeal and grievance rights?
What should staff prioritize when addressing member issues to ensure proper handling?
What should staff prioritize when addressing member issues to ensure proper handling?
Who is permitted to file an appeal on behalf of a member?
Who is permitted to file an appeal on behalf of a member?
Why is it important to distinguish between complaints and denials (which lead to appeals)?
Why is it important to distinguish between complaints and denials (which lead to appeals)?
What is a key characteristic of an 'enrollee' in the context of Medicaid plans and appeal rights?
What is a key characteristic of an 'enrollee' in the context of Medicaid plans and appeal rights?
Under what circumstances can an expedited appeal be opened without waiting for a written request from the member?
Under what circumstances can an expedited appeal be opened without waiting for a written request from the member?
What's the main difference between PHI authorization and the right to file an appeal on behalf of a member?
What's the main difference between PHI authorization and the right to file an appeal on behalf of a member?
If a member is disagreeing with a Molina decision, how should the issue be handled?
If a member is disagreeing with a Molina decision, how should the issue be handled?
Who has the authority to appoint an authorized representative to file an appeal on a member's behalf?
Who has the authority to appoint an authorized representative to file an appeal on a member's behalf?
When identifying the distinction between a complaint and an appeal, what is the primary factor to consider?
When identifying the distinction between a complaint and an appeal, what is the primary factor to consider?
Why are expedited appeals treated differently from regular appeals?
Why are expedited appeals treated differently from regular appeals?
An individual who is not enrolled in a Medicaid plan approaches you, dissatisfied that they believe they should be enrolled. Are they entitled to appeal and grievance rights?
An individual who is not enrolled in a Medicaid plan approaches you, dissatisfied that they believe they should be enrolled. Are they entitled to appeal and grievance rights?
Why do PHI authorizations not allow a person to file an appeal on the member's behalf?
Why do PHI authorizations not allow a person to file an appeal on the member's behalf?
When handling a complaint versus denials, what specific elements are vital to identify for proper resolution?
When handling a complaint versus denials, what specific elements are vital to identify for proper resolution?
Flashcards
Who can file an appeal for a member?
Who can file an appeal for a member?
An authorized representative appointed by the member or the member's provider who can file an appeal on behalf of the member.
When is signed consent required for appeals?
When is signed consent required for appeals?
It is required when someone other than the member is appealing. Note: PHI authorizations do not allow a person to file an appeal.
What is an enrollee?
What is an enrollee?
An eligible individual enrolled in a Medicaid plan; not entitled to Appeal and Grievance rights if they are not enrolled.
How should member disagreements with Molina decisions be coded?
How should member disagreements with Molina decisions be coded?
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What distinction is important to identify?
What distinction is important to identify?
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When to offer expedited appeals?
When to offer expedited appeals?
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Study Notes
- A member or their authorized representative/provider can file an appeal on the member's behalf.
- Signed consent is needed from the member if someone else is appealing.
- PHI authorizations only allow others to hear information and do not allow a person to file an appeal or grievance on the member's behalf.
- An enrollee is an eligible person enrolled in a Medicaid plan and is entitled to Appeal and Grievance rights.
- If an individual is not enrolled with the plan then they are not considered an enrollee and therefore not entitled to Appeal and Grievance rights.
- Non-members who are dissatisfied and think they should be enrolled are an example of this.
- Any issue if a member disagrees with a Molina decision (denial) should be coded as an appeal, and not a grievance.
- The distinction between handling a complaint versus denials, reduction changes, or proper resolution times, is important to identify.
- Expedited appeals should not be offered to callers unless the caller states it is an urgent/expedited request.
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