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