Across
- 4. Type of appeal that is also called an urgent appeal
- 5. Any individual or group of individuals who provide a health care service
- 6. Type of appeal review that is related to coding and reimbursement
- 9. Type of appeal that is subject to non-urgent timeframes
- 10. A statement that relates the adverse determination to the condition or treatment plan
- 11. The practice of looking at additional information that is submitted after an adverse determination has been made to see if it can result in an overturn of the original appeal determination
- 12. Intake of communication from the provider advising of planned services
- 13. Delivery or written or verbal information regarding Utilization Management determinations
- 14. Timely formal request to provide a review of a previous adverse determination
- 15. Type of determination where there is a change in the initial adverse determination decision
Down
- 1. Type of determination where the initial adverse determination is not reversed after a full and fair review of the appeal request
- 2. A request to change an adverse determination for care or services that have already been received by the member
- 3. Type of appeal review where the clinical record is evaluated to make a determination
- 7. An administrative or clinical decision made by thorough review of relevant information
- 8. Prompt rediretion of a request for service to the appropriate area for priority review and response