What happens when a reconsideration or appeal is filed against the prudent lay reviewer’s decision?
When a reconsideration is filed by a provider, the insurance company must review the claim once more under the Prudent Lay standard.
- The reviewer must be a different person and not the initial reviewer.
- The review must be done if it is the first reconsideration request.
Any second, third, fourth reconsideration request must go through the appeals process which may differ from state to state.
However, this means it will no longer be the responsibility of the insurance company. It is recommended that providers send in all relevant documentation during their first reconsideration request of the insurance company. This will ensure the insurer has proper documentation and does not need to reject the reconsideration for lack of proper supporting documents.