#1
What is a healthcare appeal?
A formal request to reconsider a decision made by a healthcare insurer or provider
ExplanationFormal request for reconsideration of healthcare decisions.
#2
Which organization typically handles healthcare appeals in the United States?
Centers for Medicare & Medicaid Services (CMS)
ExplanationCMS typically handles healthcare appeals in the US.
#3
What is a grievance in the context of healthcare appeals?
A formal complaint about the quality of healthcare services
ExplanationFormal complaint about healthcare quality.
#4
Which entity oversees Medicare appeals in the United States?
Centers for Medicare & Medicaid Services (CMS)
ExplanationCMS oversees Medicare appeals.
#5
What is a retrospective review in healthcare appeals?
A review conducted after a medical service has been provided
ExplanationReview after medical service delivery.
#6
What is a utilization review in healthcare appeals?
A process to determine if a medical service is medically necessary
ExplanationAssessment of medical necessity for healthcare services.
#7
What is the purpose of an independent medical review (IMR) in the healthcare appeals process?
To resolve disputes between patients and insurers regarding medical necessity
ExplanationResolving disputes over medical necessity.
#8
What is the role of a patient advocate in the healthcare appeals process?
To represent patients and help them navigate the appeals process
ExplanationSupporting patients in navigating appeals.
#9
What is the difference between an internal appeal and an external appeal in healthcare?
An internal appeal is conducted within the healthcare provider's organization, while an external appeal is conducted by an independent third party.
ExplanationInternal vs. external adjudication of appeals.
#10
What is the purpose of the Notice of Medicare Non-Coverage (NOMNC) in the appeals process?
To notify patients of their right to appeal Medicare coverage decisions
ExplanationInforming patients of Medicare appeal rights.
#11
In the United States, which federal law governs the appeals process for private health insurance plans?
Employee Retirement Income Security Act (ERISA)
ExplanationERISA governs appeals for private health plans in the US.
#12
What role does the Independent Review Entity (IRE) play in Medicare appeals?
Conducting independent reviews of denied Medicare claims
ExplanationIndependently reviewing denied Medicare claims.
#13
What is the purpose of a peer review organization (PRO) in the healthcare appeals process?
To conduct independent reviews of Medicare claims
ExplanationIndependently reviewing Medicare claims.
#14
In the United States, which entity administers the External Review Process for health insurance appeals?
State Insurance Commissioner
ExplanationState Insurance Commissioners manage external review.
#15
What is the purpose of the Appeals Council in the Social Security Disability Insurance (SSDI) appeals process?
To review requests for further appeal after an Administrative Law Judge (ALJ) hearing
ExplanationReviewing requests for further appeal in SSDI.