FAQ Directory: Utilization Management, Credentialing and Provider Network

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10.15.2016 Updated: Types of denials excluded from the UM 4H file-review universe What types of denials are excluded from file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

The following types of denials are excluded from the file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

  • Denials based on medical necessity.
  • Postservice payment disputes where the member is not at financial risk.
  • Denials by the secondary insurance organization, based on coordination of benefits, when the member has not filed a claim with the primary insurance.
  • Denials of vision, dental or alternative/complementary medicine services not included in the member’s medical benefits or included as a rider.
  • Denials of duplicate claims, even if there are other reasons for the denial.
  • Denials of claims for the following reasons:
    • A service included in a bundled or case rate that is incorrectly billed separately.
    • Incorrect or missing provider billing information (e.g., tax ID).
    • The member was not eligible on the date of service.
    • Nonexistent CPT or ICD code.

UM_CR 2016