Case scenario for determining dx

[Ellen Abad]

Responding to ADR dx dementia. Data submitted inconsistent. How to explain and reverse the denial of claim

[Whispera, MSN, RN]

I'm not sure what you're asking, Ellen. Can you give more information?

[DLS_PMHNP, MSN, RN, NP]

Yes, please elaborate.

[Kabin]

Maybe it's the VA's Alternative Dispute Resolution?

Not much you can do if the pt isn't hospice appropriate per FAST, PPS..

[silverbat]

I am not sure what they are disputing. If you have a physicians diagnosis of dementia, its hard to argue that the pt doesn't have it. If this is for nursing home care with a managed care org like Molina or united healthcare, are they disputing the level of care you are wanting? You probably need to talk to the insurance/company nurse reviewer and see what info he/she is needing so you can dispute the denial. Generally speaking the company will want documentation of some sort--H&P, discharge summary, nurses/progress notes, Dr's notes, MDS, lab work, etc... Hope this is what you talking about... if not, more complete information may get you better responses.