Source of Information for Assignment: Florida State Employees PPO Plan Booklet (Effective January 1, 2015): Found in
Question:
Source of Information for Assignment: Florida State Employees PPO Plan Booklet (Effective January 1, 2015): Found in Module. Specifically, students should review "Section 3: Covered Services" and "Section 5: Exclusions".
Instructions: For each scenario, you will determine whether the service(s) will be covered based on coverage provisions in the member booklet. Indicate whether the service(s) or provider claim is approved or denied. If the service or claim is denied, provide the reason why. Each scenario should be straightforward as whether to approve or deny, and is worth 5 points.
Note: In "real-life" the scenarios are not so straightforward, and usually require a clinical opinion on whether the service is truly medically necessary and often whether the setting is appropriate. Insurance plan clinicians (e.g. UM nurses and UM medical directors), often review evidence-based medicine to base these decisions, and may consult with the patient's "prescribing" physician.
Example Scenario #10: Marc Jones received acupuncture treatment for migraine headaches at his chiropractor’s office. The chiropractor is in-network, but is not certified for acupuncture. Do you approve or deny the claim? If you have decided to deny the service, provide the patient/member with the reason for the denial.
Example Answer: #10: Claim is denied because the chiropractor is not certified for acupuncture, as required for coverage of acupuncture.
Example Scenario #11: Marc Jones received acupuncture treatment for migraine headaches at his chiropractor’s office. The chiropractor is in-network and is certified for acupuncture. Do you approve or deny the claim? If you have decided to deny the service, provide the patient/member with the reason for the denial.
Example Answer: #11: Claim is approved.
How were the example problems solved? The answers were found by reviewing coverage requirements for "acupuncture" in Section 3: Covered Services of the insurance plan member booklet, which states that acupuncture "services must be provided by a medical Doctor, a Doctor of Osteopathy, a chiropractor certified in Acupuncture, or a certified Acupuncturist."
Assignment #3: Utilization Management Scenarios
Scenario #1: Pat Shubert is seeking precertification for coverage of her upcoming breast reconstructive surgery following a mastectomy. The licensed physician has confirmed that the surgery is medically necessary and that the reconstructive surgery will be to re-establish symmetry between the two breasts. Do you approve or deny the claim? If you have decided to deny the service, provide the patient/member with the reason for the precertification denial.
Scenario #2: You have received a claim from an in-network, certified Applied Behavioral Analyst for one of your health plan members, John Smith. John Smith is aged 19 and just graduated from high school. The provider is billing for a visit where John Smith was diagnosed with autism spectrum disorder. Do you approve or deny the claim? If you have decided to deny the service, provide the reason for the claim denial for the provider.
Scenario #3: You have received a claim from Dr. Addison, an in-network, primary care physician, for a “telephone consultation” with one of your health plan members, Louise Patrick. Do you approve or deny the claim? If you have decided to deny the service, provide the physician with the reason for the claim denial.
Fundamental financial accounting concepts
ISBN: 978-0078025365
8th edition
Authors: Thomas P. Edmonds, Frances M. Mcnair, Philip R. Olds, Edward