Claims and Coding
POS 11 is for this location.
What is office?
EFT stands for this.
What is Electronic Funds Transfer?
The place of service where Choice/Connect members must receive a Pneumonia: Prevnar Pneumococcal Vaccine.
What is the medical home?
The type of HCPC code billed for medications relating to injections.
Hint: It's a letter..........
What are "J-codes"?
The name of the letter CS sends if a member needs written proof of eligibility.
What is a Still Effective Letter?
POS 81 is for this location.
What is a lab?
Whether we paid for CL 173473003500 by check of EFT, if/when the check or EFT was cashed/deposited, and whether it was bulk or a single check.
What is paper check? When is 01/18/18? What is single check?
The age/gender limits for the HPV vaccines, SPECIFICALLY types 16 and 18.
What are females for 10-25 years of age?
The benefits needed to quote for an in-office injection.
What are "Injectable Medications" and "Surgery/anesth (in office)"?
BONUS bragging points: If you included an office visit benefit as well!
The name of the letter CS sends if a member needs proof that they previously had coverage.
What is a CCC (Certificate of Credible Coverage) letter?
The tab within Claims Inquiry which shows the age of the member on the date of service being billed.
What is the Member/Provider tab?
How an in-network provider in Oregon would update their remit address with PHP.
What is contact their PR rep?
The age a member needs to be in order for no PA to be required for a Zoster/Shingles vaccination.
What is 50?
The benefits needed to quote an infusion done as outpatient at a hospital or facility.
What is the "Outpatient surgery, infusion, dialysis, chemotherapy, radiation therapy" benefit?
A provider is calling asking how they can be set up for EFT payments. This is what you'd tell them...
What is: Advise the provider to go to Provlink and reference the Electronic Transaction document. Providers can also contact their PR rep if they have additional questions.
What status 15 is for.
What is pended with errors?
BONUS Bragging Points: Can we give information out about this claim if someone calls about it?
The two days of the week that checks are cut for the commercial line of business.
What are Tuesdays and Fridays?
The clinic/place we can refer members in the Portland-metro area to obtain travel vaccinations (such as yellow fever) EVEN THOUGH they are not a covered benefit under any commercial plan.
What is the Providence Health System-Travel Clinic? (At St. Vincent's)
The benefit quote for MBR ID 100129262-00 receiving an in-office injection for J1720.
Hint: Don't forget to include PA information for that code!
What is:
OV: $15 CP, ded waived, up to $2000 oopm
Inj Med - $500 ded, 20% coins, up to $2000 oopm
Surgery & Anesth - $500 ded, 20% coins, up to $2000 oopm
J1720 - Payable, no PA required *QPAD*
What to do if a member calls in and forgot their PIN/Password for their account.
What is: Call the member back at the phone number on file and verify they did indeed just contact CS. Then proceed with changing the member's account password for future calls.
The reason why CL 183515756900 denied.
What is not a covered benefit?
BONUS Bragging Points: Whose responsibility does it fall to?
The definition of withhold.
What is: Withhold is for providers who have what is called a risk contract- they have an amount taken out of each payment throughout the year, then if it is determined by PHP that they meet their quality measures, then they will get that money back as opposed to potentially owing at the end of the year.
Certain immunizations are not covered due to these purposes. (WHY the member is getting them done...)
What are "Immunizations/Vaccines for Travel, Work or School"?
The number of different medications injected into MBR ID 100233378-01 for DOS 02/20/18 with Dr. Anna Macasa.
What are 2? (2 J codes were billed)
How to log a call if a member account was accessed in error.
What is:
Subject: GxMisc
Category: Entered Under Incorrect Member