[INSERT PROVIDER CONTACT INFORMATION HERE]

<Date>

<Facility Name>

<Facility Address>

<Facility City/State/Zip>

ATTN:Utilization Department

Name/Contact Info for UM Department/Director>

RE: Denial of Coverage for Inpatient Hospitalization

<Tracking or Authorization #

Member: <Member’s Name>

DOB: <DOB>

Member ID: <Member ID #

This letter is to informinsert name of facility> that the hospitalization referenced below has been reviewed by thePhysician Reviewer at Provider Organization>, <Medical Director’s Name>:

The Insert LOC>hospital days <insert denied dates> at <Name of Facility>have been denied.

Based on review of the available medical record and clinical information, the SCANMedical director/Provider Organization> has determined that the hospital days referenced above are denied for the following reason(s):

Clinical information requested Insert dates clinical was requested> was not received

Administrative Hospital Delay (Ordering/arranging for diagnostictesting/treatments/therapies,including physical therapy, consultation/surgical-other procedures or test results that will likely result in a longer length of stay than if care were provided/arranged efficiently)

Did not meet InterQual Acute Care Criteria for Admission

Specify criteria or medical necessity not met--indicate at what level of care more appropriate>

Did not meet InterQual Acute Care Criteria for Continued Stay

Specify criteria or medical necessity not met--indicate at what level of care more appropriate>

Other: <Describe>

Additional comments:Specify information not received, or more information about specific reasons for denial>

If Insert Name of Facility> is aware of relevant information which may affect thisdetermination, please contact your UM representative <Insert Provider Group or SCAN contact name and # within one business day of receipt of this notice.

Please note that the member or patient may not be billed for these services under the terms of your SCAN Health Plan Provider Agreement AND/OR your contract with Medicare.*

Medicare Managed Care Manual Ch. 4 Section 180.1,Note:UnderOriginalMedicarerules,anOriginalMedicareparticipatingprovider(hereinafterreferredtoasaparticipatingprovider)isaproviderthatsignsan agreement withMedicaretoalwaysacceptassignment.ParticipatingprovidersmayneverbalancebillbecausetheyhaveagreedtoalwaysaccepttheMedicareallowed amountaspaymentinfull.

Sincerely,

<Insert Medical Director Contact Information at SCAN Health Plan or Provider Organization>

*Balance billing Medicare members for Medicare covered services is expressly prohibited. All entities balance billing SCAN members will be reported to the SCAN Special Investigation Unit for appropriate Fraud, Waste, and Abuse examination, assessment, and action.

CLAIMS DISPUTES

ForProvidersthatarecontractedwithSCANHealthPlan:

If you believe the determination on any claim is incorrect, you may request reconsideration. The Medicare ClaimsManual, Chapter 29 Section 310 states in part:A party dissatisfied with an initial determination may request that the contractor review its determination. A redetermination is the first level of appeal after the initial determination on Part A and Part B claims. It is a second look at the claim andsupporting documentation and is made by an employee that did not take part in theinitial determination.

  • Section 310.2 states in order to request a dispute, you must submit your request in writing no later than 120 days after the date of receipt of the notice of initial determination.
  • You must mail the reconsideration to the plan at the address below:

SCAN Health Plan Claims

PO Box 22698

Long Beach CA 90801

For Providers that are not contracted (“Non-Contracted”) with SCAN Health Plan:

  • You have the right to request a reconsideration of the plan's denial of payment;
  • You have 60 calendar days from the remittance notification date to file the reconsideration;
  • You must include a signed Waiver of Liability (WOL) form holding the enrollee harmless regardless of the outcome of the appeal. A copy of the WOL is available by accessing this link:
  • You should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports your argument for reimbursement
  • You must mail the reconsideration to the plan at the address below:

SCAN Health Plan Claims

PO Box 22698

Long Beach CA 90801

Y0057_SCAN_9118_2015 IA 08202015 U1 2017