Compliance One Source

1. Use this JA for the process steps for general appeal handling.
3. Use this JA to assist with documentation of appeals.
7. Use this JA when a member request to have the plan cover a specific medical service.
10. A request to have the plan cover a specific medical service.
12. Use this JA to identify status of CD.
14. What JA would you use to assist with appeal dismissal?
16. A request to have the plan change a decision for a denied prior authorization or claim.

2. What JA should be used for grievances?
4. What must be on file prior to submitting an appeal unless member disagree with the processing or responsibility of a claim?
5. What JA would you use when handling caller who is threatening media or legal complaint regarding a UHC policy.
6. A request to have the plan cover a Part D drug.
7. What JA would you use to help with complaints about policy that excludes a medication, but member is not disputing that a medication is not covered.
8. What kind of cases (authorizations) are not considered denials?
9. Use this JA to help member obtain medical care in a timely manner when the member experiences a delay in receiving treatment.
11. A complaint (or any expression of dissatisfaction) about the health plan or health plan representative, regardless of whether the caller is requesting a resolution.
13. Who handles dental appeals?
15. Which intent should you use to document the interaction when dealing with appeals?