Preventative Care
This service commonly takes place in the outpatient setting and is done once per year by Females over 40 years of age.
Mammogram
This is the phrase we use when quoting benefits to in Network providers.
Contracted Rate
These are the benefits you will need to quote when giving benefits to Providers.
Facility
Physician
Facility Ancillary
Any thing over this amount of hours is considered In Patient.
23 Hours
This is they system we use for call taking.
One view
Preventative Care Can Take Place in any of these settings.
OP
Office
Convivence Care Clinics
Ancillary Centers
Where do we got to determine the Assignment of benefits on a claim
The Original 837 (Claim Level Information)
What Happens with an OP claim for Anesthesia if the Anesthesiologist is out of Network?
As long as there is a finalized facility claim on file that processed in network we will enhance the anesthesia claim to the in network level.
What charges (claims) can you expect with an In Patient Claim for Maternity
Facility for Mom
facility for baby
Physician Mom
Physician baby
Ancillary charges mom and Baby
We use this system to track calls backs when one is needed.
FMS follow up Management Tool
What will we look for in the benefit Details to determine if the plan follows the Affordable Care Act?
Grandfathered ( does not follow)
Not Grandfathered (Follows)
This "Phrase" Does not need to be set for:
Family Planning
Preventative Care
Mental Health
or sensitive Diagnosis
Services when quoting claims
Base On Medical Necessity
Name some services that require preauthorization that may take plane in the out patient setting.
MRI or CT scans, PET and CAT Scans, Nuclear Medicine and some Cardiac Diagnostic testing
How long will Cigna automatically approve an Inpatient hospital stay for the delivery of a baby? Is authorization required beyond this time frame?
48/96
We use this system to identify correspondence sent to us by providers or customers. Correspondence can be medical records, clinical information, or letters send or sent by customers or providers.
FILE NET
What is Preventative Care
Preventive care helps detect or prevent serious diseases and medical problems before they can become major. Annual check-ups, immunizations, and flu shots, as well as certain tests and screenings, are a few examples of preventive care. This may also be called routine care.
What tab do we go to see what payment was made, who it was made to and what form the payment was made in? (facets)
Remittance
Name some OP Ancillary Services
labs
x-rays
therapies (PT OT)
Rehab for drug and alcohol dependency
If a customers enters a hospital through the ER and is admitted to stay In patient for a week and that hospital was out of network will we pay the In patient claims as In Network.
Yes, Entrance to a hospital from the ER and transferred to In patient means we will pay In Patient at the In Network Level.
We use this system to look up Prior authorizations, Transition of care and Continuity of Care Requests
True Care
Colonscopy
Explain the out of network process that claims take for processing.
Funnel:
NPS Network Savings, BNS, MRC, Billed Charges.
Tell me the outpatient revenue codes for diagnostic radiopharmaceuticals.
343
Is a prior authorization required for an In Patient hospital stay for 10 days?
Yes
What system do we use to track and get information on overpayment Requests.
CORS