MHS
Which MHS screen is the Source of Truth for Provider Tax ID?
PR1011
When validating member information, how many demographics need to match?
2 out of 4
Double Jeopardy:
What are the 4 member demographics we validate?Which hold code do you apply to a claim to deny for No Authorization?
Hold Code JN
Name one Place of Service (POS) that is a 9R exception
POS 20 or 23
What is the first step you perform for every single claim you work?
Validation
Which MHS screen can you find Member DOB?
ME1014
[Can also be found in CL1034 in the gray box after pressing Next one time]
What MHS screen will you utilize for HC 07 - Age Invalid for Procedure?
RF1031
True or False: If Hold Code VL generates and you find a valid authorization, you can add Y to the PRC field to waive the authorization requirement and pay.
FALSE. If VL is on a claim, we want to apply the authorization to the claim directly; we would not put Y in PRC (unless instructed to do so by the HelpDesk)
If your claim has Hold Code 9R and does not meet criteria for payment, which Hold Code do you Add to the claim?
Hold Code 9Q
Which 2 companies do we work?
Company 01 and Company 20
In CL1011, how do you review the next authorization on file?
In Navigation Menu: Enter Next Authorization
Double Jeopardy:
True or False - You can also use Pg Dn on your keyboard
For Observation Stays (Hold Code !4), how many units of G0378 need to be billed in order for the service to be payable?
8 Units
Double Jeopardy:
If the claim bills less than 8 units, which hold code do you apply to deny the Observation Stay?
Which modifier indicates the claim is billing the Professional Component or a service? (i.e. Professional Interpretation)
Modifier 26
If a member is within their first 60 days of enrollment, which screen do you go to in order to see which providers they are restricted to seeing?
ME1082
Hospitals/Facilities bill on this claim form
UB, UB-04, Institutional Claim Form
Which MHS screen can you go to review Value Codes?
(Hint: Value Codes are only submitted on UBs)
CL1035
Codes tab
If you have a Newborn claim submitted under Mom's CIN, before submitting a SF, which screen do you go to in order to check if there is a Newborn CIN on file?
ME1014
To Check For Newborn CIN:
Copy and Paste the Subscriber # into the Member # Field
Review + Enter
ND (Next Dependent) + Enter
+ Enter until you find a member with same DOB on claim image
True or False: If the Dashboard returns UNMATCH and Claim Requires Global Auth exception, you must perform a full traditional search to find a valid auth/auth exception.
True
Non-Emergency Transportation is a 9R exception for which Enrollment Tier?
(Hint: The Enrollment Tier is a location in NY)
Long Island (LI)
Emergency Transportation is always a 9R exception.
Non-Emergency Transportation is only a 9R exception for Long Island members.
POS 41 = Transportation. You can review the procedure code descriptions in RF1031 to determine if it is emergent or non-emergent transportation
What is Place of Service (POS) 22?
OP Hospital
Which MHS screen shows the provider's specialties?
UM1021
Which two Provider fields must be validated?
*Provider Name - Checking for a *
If the Authorization Dashboard returns a Weak Match to an auth beginning with CCNA, which Delegated Vendor would we go to in order to review the authorization?
EviCore (CareCore National)
What does Hold Code 9R mean?
(i.e. Why would a claim have Hold Code 9R)
The member has been placed in the Recipient Restriction Program by the Office of the Medicaid Inspector General (OMIG) for having demonstrated a pattern of abusive utilization services.
The member is limited to seeing their PCP, members of the PCP's group, and other providers referred by the PCP.
(Hint: The status code is a single letter)
R
R = Ready
Ready to be processed on the next check run