A |
|
Attempts to rescind or modify an authorization for health care services; |
B |
|
Bills that have not been timely paid, contested or denied; |
U |
|
Underpayment or nonpayment of claims; |
S |
|
Submission requirements in a physician contract for medical records that are not reasonably relevant; |
E |
|
Explanations that fail to set forth the specific reasons for denying, or contesting a claim; |
|
|
|
M |
|
Misdirected claims that are not properly forwarded; |
A |
|
Acknowledgement failures concerning the receipt of physician disputes; |
T |
|
Time periods for physician dispute filing deadlines that are inconsistent with the law; |
T |
|
Time periods for resolution and written determinations concerning a physician’s dispute not met; |
E |
|
Emergency services claims that resulted in unreasonable requests for submission of medical records that are not reasonably necessary to determine liability; |
R |
|
Required schedule of fees and other information not provided to contracting physicians; |
S |
|
Schedules of fees and other disclosures modified without proper notification to contracting providers; |
|
|
|
R |
|
Required provisions in a plan’s contract with the plan’s claims processing organization; |
E |
|
Establish (failing to) that requests for medical records are reasonably relevant; |
A |
|
Accepting (failing to) late claims under appropriate circumstances; |
C |
|
Claims filing deadlines that are inconsistent with the law; |
T |
|
Time periods to acknowledge receipt of claims not met; |
|
|
|
N |
|
Notices of provider dispute resolution mechanism not provided;
|
O |
|
Overpayments demanded too late and not requested to be reimbursed properly;
|
W |
|
Waivers required from physicians of certain Knox-Keene protections. |
| |
|
|
