Pharmacy Behavioral Health Generic. An appeal submitted by a Provider on the Member’s behalf is to be reported under Member Appeal Activity. Sample Layout: Member Appeal Activity COS Category of Service (COS) Description Beginning Balance Ending Balance Received Resolved Appeals Extended by 14 Calendar Days Total Expedi xxx Non Expedi xxx Total Expedited Resolved in 3 Working Days Non Expedited % Resolved in 30 Calendar Days Non Expedited Average Days for Resolution Written Notice of Resolution within 30 CalendarDays Expedited Non Expedited Oral Written Oral Written 5 Working Days Written Notice Provided Final Disposition Moved to Non Expedited Oral Abandoned Final Disposition Upheld Overturned Partially Overturned Upheld Overturned Partially Overturned Medicaid Mandatory Services 02 Inpatient Hospital 12 Outpatient Hospital Medicaid Optional Services 03 Mental Hospital Provider Appeal Activity Provider Type/Category Beginning Balance Ending Balance Received Resolved Appeals Extended by 14 Calendar Days Total Oral Written 5 Working Days Written Notice Provided Total Resolved in 30 Calendar Days Average Days for Resolution Written Notice of Resolution within 30 Calendar Days Oral Abandoned Upheld Overturned Partially Overturned Inpatient Outpatient Unknown Type Reporting Criteria: Terminology Definition Date Format All report dates not otherwise specified are to be in the following format: mm/dd/yyyy Row Label Description COS Two character designation for a state specific category of service. Crosswalk may be found in Exhibit D. Category of Service (COS) Description A description for the ‘COS’. Medicaid Mandatory Services State covered Medicaid services required by federal law. Subtotal: Mandatory Services Calculated field. Sum total of all services listed as mandatory services For columns with Average Days it is the average days of resolution for all mandatory services. Medicaid Optional Services State covered Medicaid services in addition to the mandatory covered services the state has chosen to cover. Subtotal: Optional Services Calculated field. Sum total of all services listed as optional services. For columns with Average Days it is the average days of resolution for all optional services. Total: Mandatory and Optional Calculated field. Total of all mandatory and optional services. For columns with Average Days it is the average days of resolution for all mandatory and optional services. Provider Type/Category Crosswalk of Provider Type and Provider Specialty to each Provider Descriptio...
Pharmacy Behavioral Health Generic. An appeal submitted by a Provider on the Member’s behalf is to be reported under Member Appeal Activity. Sample Layout: Member Appeal Activity COS Category of Service (COS) Description Beginning Balance Ending Balance Received Resolved Appeals Extended by 14 Calendar Days Total Expedi xxx Non Expedi xxx Total Expedited Resolved in 3 Working Days Non Expedited % Resolved in 30 Calendar Days Non Expedited Average Days for Resolution Written Notice of Resolution within 30 Calendar Expedited Non Expedited Oral Written Oral Written 5 Working Days Written Notice Final Disposition Moved to Non Expedited Oral Abandoned Final Disposition Upheld Overturned Partially Overturned Upheld Overturned Partially Overturned Medicaid Mandatory Services 02 Inpatient Hospital 12 Outpatient Hospital Medicaid Optional Services 03 Mental Hospital Provider Appeal Activity Provider Type/Category Beginning Balance Ending Balance Received Resolved Appeals Extended by 14 Calendar Days Total Oral Written 5 Working Days Written Notice d Total Resolved in 30 Calendar Days Average Days for Resolution Written Notice of Resolution h a n a a Oral Abandoned Upheld Overturned Partially Overturned Inpatient Outpatient Unknown Type d ei v o r P s Dy r
