The following types of denials are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO):
- Denials based on benefits that underwent a medical necessity review, which determined there was a benefit exclusion.
- Denials based on failure to follow the organization’s reasonable filing procedures. (i.e., lack of timely filing, lack of prior authorization).
- Auto-adjudicated claims denials or point of service (POS) claim denials that were not based on medical necessity (excluding duplicate claims).
- Denials not listed above that are not based on medical necessity, such as reversals or prior decisions due to fraud or improper billing.
UM_CR 2016