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Results for “Insurance Claim Review”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

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At least 397 records · Page 22Linked to original sources
PubMed1998

Reconsideration of denied claims--VA. Proposed rule.

This document proposes to amend the Department of Veterans Affairs' "Medical" regulations by adding a new section to set forth reconsideration procedures available if requested by an individual or entity who made a claim for benefits administered by the Veterans Health Administration and who disagrees with the initial decision denying the claim. It is anticipated that these procedures would not only allow for more reflective decisions at the local level but would also allow some disputes to be resolved without the need for further appeal to the Board of Veterans Appeals.

Data Collection↗
PubMed1998

Recourse for pediatric denials.

Providers and parents are often frustrated by payors' denials of coverage for reasons such as "medically inappropriate" or "no skilled care necessary." Though the battles may seem insurmountable, recourse is available--and the successes are worth the legal battles.

Child↗
PubMed1997

Issues of medical necessity: a medical director's guide to good faith adjudication.

The term medical necessity is difficult to define, a problem for insurers who need to clearly describe what is and is not covered in their contracts with subscribers. An unclear, vague definition of medical necessity leaves insurers vulnerable to litigation by subscribers denied care deemed medically unnecessary. To avoid lawsuits, insurers must make every effort to educate their subscribers about their medical coverage, going beyond merely providing a lengthy subscriber handbook. In decisions on medical necessity, medical directors at insurance companies play a key role. They can bolster the insurer's position in denial-of-care cases in numerous ways, including keeping meticulous records, eliminating unreasonable financial incentives, maintaining a claims denial database, and consulting with other insurers to achieve a consensus on medical necessity.

Decision Making, Organizational↗