Informal Reconsideration Requests

AKA "Appeals"

Full Continuum Behavioral Health Consultants
Memphis, Tennessee USA

Phone: (901) 438-8755
fcbhc@att.net


Service

We assist those who have had non-ambulatory psychiatric care (hospital "acute" care or residential treatment) "denied" (i.e., "not certified") by a Third Party Payor (Insurance, Medicaid, CHAMPUS, etc.). This means they will not cover the cost of the care provided, leaving the patient/guarantor responsible for the bill.

Method

We work with the Provider. Facility Administrators can contact us at Full Continuum and send us a copy of the clinical record, a copy of the denial letter specifying dates of service not certified and why, along with a signed release of information.

We will work up the medical record using clinical software developed by Full Continuum. If our own medically necessary criteria are met, we will write a letter requesting Informal Reconsideration.

We then send back to the facility a packet containing: 1) the Reconsideration Request letter, 2) the copy of the chart reviewed, and 3) clinical software reports we used to assess the record, i.e., The Clinical Index of Stress form with Interpretive Summary and an AutoGenerated GAF (Global Assessment of Functioning Scale*) to be submitted to the Third Party Payor by the Provider.

We mark the clinical record to flag for the Third Party Payor where we found the clinical information on which our medically necessary justification is based. We forward these back to the facility for the treating physician to review and sign (not as author, but as an endorsement of its contents; the lead paragraph of our letter explains the authorship to the Third Party Payor) for submission as an Informal Reconsideration Request.

Fee

The fee for our service is $300.00 for a length of stay of up to 10 days and $100.00 is added for each additional 10 days of stay. For example, an 11 day length of stay (the date of discharge is not counted in the total unless the Admit Date and Discharge Date are the same) would be billed at $400.00. The shipping charge is additional, as a pass through.

If we work up the record and determine the care did not meet medically necessary criteria, $300.00 will be charged and no letter will be generated. The copy of the clinical record will be returned to the facility and possibly an "External Review" which specifies the problems identified in reviewing the record (at our discretion). The External Review is aimed at improving the quality of behavioral healthcare. It is, therefore, a proprietary service solely for the purview of the Provider (not the patient or the Third Party Payor).

Once we receive the copy of the clinical record, we will review it and send an e-mail directing you to a website for you to use PayPal for the fee.

Once a facility/system establishes a track record with us, we will draw up an Agreement and once executed, billing occurs on a monthly basis.
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  • Clinical Software

    Full Continuum Home

    We have been providing this service to hospital systems in 10 States since 1995. No guarantees are expressed or implied.

    *The Global Assessment of Functioning (GAF) Scale form is adapted and reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association.


    We reserve the right to reject submissions wholly at out discretion.

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    Webpage contents last modified on January 12, 2007.