Brand New Day apologies for the technical difficulties preventing the webinar timely start. of the webinar.
Brief summary to review and clarify topics discussed. We appreciate your attendance.

After introduction of all participants, BND provided details regarding an appeal request made by BND member managed under CFC; appeal rights were not sent to the member. Conifer explained all claims in question were reviewed by a medical professional; hence denial using code DMR (not medically indicated), however a Notice of Denial of Payment was not issued to member AND provider per regulation. Email communication is to recount recounting conversation with Conifer employee in Claims department “members do not receive denial letter from claims” only …show more content…
For use when IPA has confirmed that there is no authorization on file and medical records requested/received do not meet medical necessity requirements. Requires UM review.: Both Member and Provider must receive notice.
BND Claims staff suggested use of Washington Publishing Company, a nationally recognized source for Claim Adjustment Reason Codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/. BND team presents - audits reveal continued deficiencies in timeliness of acknowledgement of claims – continued discussion deferred to later date offline.
UM/Concurrent review – closing inpatient authorizations. BND staff presents documentation demonstrating inconsistency with closing authorizations; specifically inpatient status authorizations that based on medical review / criteria are downgraded to observation status only. In this instance:
The facility AND member must receive a Notice of Denial from IPA stating the denial reason based on medical necessity, and applicable