DENIALS AND APPEALS

PRE-CERTIFICATION DENIALS

Question: What is a pre-certification?
Answer: A pre-certification is an approval that you receive for a procedure BEFORE the procedure is done.

Question: What is a pre-certification denial?
Answer: A pre-certification denial is a decision that has been made to deny a doctor's request to perform a procedure. This decision is made by the Medical Director of the Cooperative.

Question: Why would a pre-certification request be denied?
Answer: There are several reasons why a pre-certification request may be denied. Some reasons may include the following:

• A lack of or incomplete medical information from the physician's office.
• Medical information provided by the physician's office does not support the need for the test/procedure according to the criteria used by the Cooperative.
• Other tests or treatments need to be done before pre-certification can be approved.

Question: How will I know if pre-certification has been denied?
Answer: If pre-certification is denied your physician will be notified by telephone and you and your physician will receive notification letters in the mail. The notification letters will be sent within 24 hours of the decision to deny the pre-certification. The notification letters explain the exact reason for the denial. You should discuss the reason for the denial with your physician to decide whether or not you want to appeal or challenge the decision. If you decide to appeal, you or your physician must send a letter to the Cooperative that specifically states, "I want to appeal the pre-certification denial for __(list the service(s) and why you want to appeal)________". Appeals can be processed more quickly if they include as much medical information as possible specifically related to the reason for the denial. The Cooperative must receive the appeal within 180 days of the date on the notification letter you received. Once the appeal has been reviewed, you will receive written notification of the outcome of the appeal.

CONTINUED HOSPITAL STAY DENIALS

Question: What is a continued hospital stay denial?

Answer: When you are in the hospital, the nurses at the Cooperative work with the nurses and doctors at the hospital to make sure you are receiving the care that you need. If you are in the hospital and the Cooperative Medical Director feels there is a more appropriate level of care for you, he will deny your admission or continued stay in the hospital.

Question: What are the reasons why my stay in the hospital may be denied?
Answer: There are several reasons why some of the days you were in the hospital may be denied. They might include:

• The care you received could have been safely provided in another setting, such as outpatient, at home with home health, or in a skilled nursing facility
• There was a delay in receiving the test/procedure/surgery you needed and the delay was not for a medical reason

DENIAL PROCESS: If some hospital days are denied, the hospital will be notified by telephone and you and your physician will be sent notification letters within 24 hours of the determination of the denial. The notification letters state the exact reason for the denial. IF YOU WERE A PATIENT IN A NETWORK HOSPITAL, YOU ARE NOT FINANCIALLY RESPONSIBLE FOR THE DENIED DAYS. You should discuss the reasons for the denial with your physician to decide whether or not you wish to appeal. If you decide to appeal, you or your physician must send a letter to the Cooperative that specifically states, "I want to appeal the denial for __(list the service(s) and why you want to appeal)________". Appeals can be processed more quickly if they include as much medical information as possible, specifically related to the reason for the denial. The Cooperative must receive the appeal within 180 days of the date on the notification letter you received. Once the appeal has been reviewed, you will receive written notification of the outcome of the appeal.

REFERRAL DENIAL

Question: What is a referral denial?
Answer: A referral denial is a decision that has been made to deny a doctor's request to send you outside the PHVCC network.

Question: Why would a referral request be denied?
Answer: There are several reasons why a referral request may be denied by the Cooperative. They may include:

• There are providers within the Patoka Valley Health Care Cooperative network that can provide the care.
• The physician/facility the patient is being referred to is not a Sagamore provider

DENIAL PROCESS: If a referral is denied, you and your physician will be sent notification letters within 24 hours of the determination of the denial. The notification letters state the exact reason for the denial. You should discuss the reasons for the denial with your physician to decide whether or not you wish to appeal. If you decide to appeal, you or your physician must send a letter to the Cooperative that specifically states, "I want to appeal the denial for           (list the service(s) and why you want to appeal)         ". The appeal should specifically address the reason for the denial. You will receive written notification of the outcome of the appeal.

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