APPEALABLE DENIALS OR FIGHTABLE COURSE OF ACTION NJ NY

MDR (MEDICAL DIRECTOR REVIEW) APPEAL DIRECT ARB

PAR (PHYSICIAN ADVISORY REVIEW) APPEAL DIRECT ARB

BUT MAKE SURE YOU STUDY THE DATE WHEN THEY APPLY THE
MMI (MAXIMUN MEDICAL IMPROVEMENT) MMI ON CLAIM IT SHOULD BE BEFORE OUR DATE OF SERVICE APPEAL DIRECT ARB
NOT RELATED TO ACCIDENT VERIFY THE DATE OF LOSS INTO
DENIED BASED ON UTLIZATION REVIEW
50% PRECERT PENALTY NO PRECERT IS REQUIRED IN NY APPEAL ONLNOT VALID
IF THE INSURANCE DELAYS THE BILL FOR OVER 60 DAYS AFTER THEY
NON PAYMENT APPEAL RECEIVE IT,THEN FILE A NON PAYMENT APPEAL ON IT.
INCOSISTENT WITH CLINICALLY SUPPORTED SYMPTOMS APPEAL DIRECT ARB
NEED ADDITIONAL PAPER WORK TO SUPPORT MEDICAL NECESSITY
TREATMENT PERFORMED IS NOT MEDICALLY NECESSARY
CLAIM HAS BEEN DENIED BASED ON THE RESULTS OF IME (INDEPENDENT MEDICAL EXAMINATION)
BASED ON RESULTS OF IME
NON CERTIFIED- BASED ON A MEDICAL DIRECTOR REVIEW
PURSUAN TO N.J.A.C CODES IN APPENDIX EXHIBIT 1 THAT DON’T HAVE AN AMOUNT IN THE ASC FACILITY FEE
COLUMN ARE NOT REIMBURSABLE IF PERFORMED IN AN ASC
DENIED AFTER REVIEW OF DOCUMENTATION TREATMENT IDENTIFIED AS NOT MEDICALLY NECESSARY
PRE-CERT PENALTY APPEAL AFTER PAYMENT (50% PENALTY)
PENDING ELIGIBILITY MORE THAN 60 DAYS.

NON-APPEALABLE/ DEAD DENIALS/ Request LOP/ BILL PATIENT ATTORNEY

BENEFITS EXAHUSTED/ BENEFITS TERMINATED/ POLICY LIMIT EXCEEDED/ NO MORE BENEFITS AVAILABLE
PATIENT IS NOT ELIGIBLE FOR PIP BENEFITS
THERE IS NO PIP COVERAGE AVAILABLE
CLAIM HAS BEEN DENIED FOR LACK OF CO-OPERATION
CLAIM HAS BEEN DENIED FOR NON- COMPLIANCE
ELIGIBILITY HAS BEEN DECLINED
DOLLAR A DAY POLICY
POLICY CONTAINS ER BENEFITS ONLY (EMERGENCY ROOM SERVICES)
MISSING OF IME
MISSING OF EUO (EXAMINATION UNDER OATH)/ NEGATIVE EUO
THE ALL ALLOWED AMOUNT APPLIED TOWARDS DEDUCTIBLE
ER BENEFITS ONLY