Q: list four claim determinations that can be appealed? and what steps would you take and why? Explain what an uncollectible account is? Briefly explain procedures required for submission of an appeal
A: There are four types of appeals:
? Medical Necessity - Based on whether the care is appropriate, reasonable, and
adequate for the beneficiary?s condition
? Factual Determination - Factual determinations involve issues such as
coverage, [ provider authorization (status) requests, or denial of a provider?s
request for approval as a TRICARE provider
? Dual-eligible beneficiary
(Medicare-TRICARE eligible beneficiaries) - When
Medicare and TRICARE have both denied a claim and the beneficiary has
successfully appealed the Medicare claim (Medicare paid the claim), the
beneficiary can then appeal the TRICARE denial
? Provider Sanction - When a provider has been denied approval as an
authorized TRICARE provider or who has been terminated, excluded,
suspended, or otherwise sanctioned. Read more at ]
Rating
There are no new answers.
