Claims and Coding
POS 21 is for this location.
What is inpatient hospital?
EFT stands for this.
What is Electronic Funds Transfer?
The definition of an appeal.
What is: The process in which a member or provider requests the health plan to reconsider a decision. Members can appeal denied prior authorizations or if a claim was denied to the member.
This happens if a Choice member is seen without a referral.
What is the claim processes out-of-network?
The location code (POS) that an immediate care bills for services.
What is POS 11?
BONUS Bragging Points: What benefit(s) do we quote to the member?
Status 81 means this.
What is a PBH claim, encounter data?
Whether we paid for CL 173473003500 by check or 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 definition of a grievance.
What is an expression of dissatisfaction or dispute that is not regarding a prior authorization denial or claim denial.
Why claim 173545256100 required a referral.
What is the member had an office visit with a specialist and those require a referral.
The main difference between an immediate care and an urgent care.
Hint: think about how and who usually bills us
What is Urgent cares usually bill as a facility (or with a specific location code indicating POS UC) whereas immediate cares usually bill us as an individual doctor with the location code of an office visit.
The tab within Claims Inquiry which shows the age of the member on the date the claim was processed.
Use Claim: 180094147200 if needed
What is the Member/Provider tab?
This is who a participating Oregon provider would talk to about address changes or anything else they may need to update with PHP.
Hint: KMS - Providers and Networks topic
Who is their PR rep?
The number of levels an ASO member has for an appeal.
What is 3?
BONUS Bragging Points: How many levels would they have if they filed a grievance?
The reason why a referral is not attached to claim 171585075000.
What is a referral was not required because the claim was for outpatient services at a hospital.
The benefit you would quote for member 10010617700 if they were going to Providence Medical Group Scholls Immediate Care in Tigard.
What is $250 deductible, $10 copay up to the $1500 oop max. $0 met for the deductible, $0 met for the oop max.
Xray/labs are CIF with a participating Immediate Care.
What CPT 30420 is for and whether or not it is a covered code.
What is Rhinoplasty, PA required?
BONUS: Why does this service require a PA?
The day of the week checks are cut for ASO and the day(s) of the week they are mailed.
What are Fridays and Monday/Tuesday?
The main way a member needs to file an appeal or grievance, and the three ways it can be received (with specific information where to send it).
What is write a letter and:
1. Mail it to: P.O BOX 4158, Portland, OR 97208-4327
2. Fax it to: (503)574-8757 or (800)396-4778
3. Email it to: phpappealsandgrievances@providence.org
The steps to take in order to filter claims to see what claim number(s) are attached to a referral # on file.
Use member # 11293213800 and referral #180801257 if needed.
What are: Transfer into Claims Inquiry > Load all the claims > Filters > Criteria > Selections: UM Referral ID > Value: Referral ID # ?
Whether or not ancillary services (x-rays/labs) are included in the ER benefit.
What is yes? Everything done in the ER falls to the ER benefit listed on the benefit summary.
Unlike UC/IC, where it applies to the applicable benefit.
What line 4 is for on CL 180435616700 and if it the code requires a PA.
Hint: HCPCS grid.
What is J1100, Dexamethasone Sodium Phosphate, no PA required?
BONUS: QPAD!
The definition of withhold on a claim.
Hint: KMS Claims
See claim 180874764200 for an example. Line item details tab, third column over in the details portion of the screen.
What is: A withhold is an amount of money withheld from each claim when a provider has a risk contract with PHP. At the end of the financial year PHP will determine if the provider has met the quality measures in their contract. If it is deemed the provider has met their quality measures, then PHP will pay the provider the withhold.
The timely filing a member has to submit an appeal/grievance and PHP's response time.
What is 180 days (for member to submit) and 30 days (for PHP to respond)?
BONUS Bragging Points: How long does PHP have to respond to an expedited appeal?
The reason why a referral is not required for Dr. James Beckerman (Barnes Rd) for MBR ID 100762504-00.
What is Seamless Access?
Dr. James Beckerman, a Cardiologist, practices under the same TIN as the member's medical home (TIN 931097258) PMG Gresham.
Whether or not claim 170204672100 is for a regular office visit with a PCP or if it is for an Immediate Care visit.
What is a claim for an Immediate Care visit. The TOS code is VOPI - Practitioner Visit Immediate Care