Escalation
Our PA assists with our DRG downgrade denials and assists UR with medical necessity denials. For DRG downgrade denials we follow the payor's process for first, second and third (when available) levels of appeal. I have escalated Medicaid denials to the state level on a rare occasion but have not found an option for escalating MCR advantage denials. Is anyone aware of any options beyond the payor's process to further escalate these denials similar to the ALJ being available from medical necessity denials?
Thank you for any feedback,
Lisa McLuckie
Comments
I am very interested in this topic as well. We have recently started our Clinical Coding Denials department. I have little or no information on escalating some of these DRG and Clinical Validation denials beyond the 1st and 2nd levels to the auditing company and 3rd level to the payer. Any help or direction is welcome.
Thank you in advance.
Shannon
shannon.dislvestro@uchicagomedicine.org
Have you asked for Peer-to-Peer (P2P) option? Some will allow and some will not. We have started requesting more P2P after the 2nd or 3rd level appeal and are finding many are getting overturned just from the request and not having to actually have the P2P call. I know we have done P2P with Optum UHC and Cotiviti Anthem.