Medicare Case Reviews: Principles of Denial Letter Writing

Activity description

Medicare health plans are required to issue a Notice of Denial of Medical Coverage, also known as an Integrated Denial Notice (IDN), upon denial, in whole or in part, of an enrollee's request for coverage and upon discontinuation or reduction of a previously authorized course of treatment. Medicare may issue denial letters for various reasons and may send a few different types of denial letters depending on the reason for denial. In this activity, you will hear Dr. Munirah Curtis review the Medicare Hierarchy and requirements for documentation of Medical Director case notes. She will also talk about principles of Medicare denial letter writing and the specific components that should be included in a denial letter.

Course last reviewed: 5/19/2023
 
Provided by
This activity is provided by OptumHealth Education and Optum Care.

Commercial support
No commercial support was received for this activity.

Hardware/Software Requirements
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Target Audience

This activity is designed to meet the educational needs of nurses, pharmacists, pharmacy technicians and physicians interested in the components of an effective denial letter.

Learning Objectives

At the end of this educational activity, participants should be able to:

  • Recognize criteria used for determination.
  • Identify important components of effective denial letters to members.
  • Examine denial letters for effective format and content.
Activity summary
Available credit: 
  • 0.50 ACPE - Pharmacists
  • 0.50 ACPE - Pharmacy Technicians
  • 0.50 AMA - Physicians
  • 0.50 ANCC - Nurses
  • 0.50 Attendance - General Attendance
Activity opens: 
05/25/2021
Activity expires: 
06/07/2024

Faculty/Planners
Sarah Chart, RN
Vice President
OptumHealth Education

Rebecca Gleason, RN, CCM
Clinical Planner
OptumHealth Education

Lolly Bilous, MSN, RN, CCM
Training Consultant 
Clinical Adherence and Remediation
Clinical Consistency and Safety
Clinical Performance
Optum Care

Munirah Curtis, MD
Medical Director
Clinical Coverage Review
Optum

Valerie Ventura, MSN, RN
Vice President
Clinical Adherence and Remediation
Clinical Consistency and Safety
Clinical Performance 
Optum Care

Tiffany Younts, MSN, RNC-OB, CCM
Training Consultant 
Clinical Adherence and Remediation
Clinical Consistency and Safety
Clinical Performance
Optum Care

Disclosures of relevant financial relationships
In accordance with the Accreditation Council for Continuing Medical Education's (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, OptumHealth Education (OHE) requires all those in control of educational content to disclose their financial relationships with ineligible companies within the prior 24 months. Ineligible companies are defined by the ACCME as companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. Individuals must disclose all financial relationships, regardless of the amount, with ineligible companies and regardless of their view of the relevance of the relationship to the education. OHE ensures that the content is independent of commercial bias.

The activity faculty or planners have no financial relationships to disclose.

Method for calculating CE credit
CE credit was calculated by the complexity of content.

Accreditation Statement
Joint LogoIn support of improving patient care, this activity has been planned and implemented by OptumHealth Education and Optum Care. OptumHealth Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

Credit Designation Statements

Nurses
The participant will be awarded up to 0.50 contact hours of credit for attendance and completion of supplemental materials.

Nurse practitioners
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Pharmacists/Pharmacy technicians
This activity is approved for 1.00 contact hour ([0.10] CEU) in states that recognize ACPE.
Attending the full program will earn 1.00 contact hour.
Unique Activity Number(s): JA0007123-9999-21-162-H04-P/T

Physicians
OptumHealth Education designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PAs
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.

Attendance
A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization with which they wish to obtain credit.

Available Credit

  • 0.50 ACPE - Pharmacists
  • 0.50 ACPE - Pharmacy Technicians
  • 0.50 AMA - Physicians
  • 0.50 ANCC - Nurses
  • 0.50 Attendance - General Attendance
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