KMS
Online Resources
Benefits
Claim Denials
PA and Referral
100
The payer ID for ZirMed.

What is PHP01?

100
The three places online you can find the Prior Authorization Request Form.
What is KMS, Provlink and the PHP External Website.
100

The benefit you'd quote for a fully large, non-grandfathered plan, for a member wanting to get a tubal ligation with an in-network provider and at an in-network facility.

*BONUS: What benefits would you quote off the benefit summary if they went out-of-network?

What is "Covered in Full"?

*BONUS: Surgery/anesthesia (prof) and Outpatient Surgery (facility)

100

The reason why CL 163490116500 denied.

What is: Denied for ST Termination?
100
This happens when a choice member sees a specialist without a referral on file.
What is "the claim processes out-of-network and therefore is not covered and falls to member responsibility"?
200
What modifier NU means.
What is DME Purchase?
200
The steps a member takes to find where they can shop for insurance.
What are: PHP Internet - Individuals and Families - Shop for Insurance 2018
200

The vasectomy benefit quote for MBR ID 100364855-00.

What is:

Any Willing Provider (no IN/OON), applies to the member's ded first (HSA plan).

$1500 DED, 20% COINS up to $3000 OOPM

200

The reason why CL 170720035000 denied.

What is: YEP - Other Insurance. Please resubmit primary EOP?
200
What has to happen after we received a retro referral on file after a claim has processed out-of-network due to referral violation.
What is "the claim needs to be reprocessed with the retro referral attached"?
300
What POS 42 stands for.
What is Ambulance - Air or Water?
300
The steps a member takes to find the member reimbursement form to fill out and submit to PHP.
What are: PHP Internet - Members - Forms - Claims: Medical claim form
300

The out-of-network benefit quote for HCPC code L3000 for MBR ID 100510336-00  (as if the member were calling - include all components you'd go over with a member.)

What is:

$5000 DED, 50% COINS, up to $14,300 OOPM with a limit of $200 PCY for custom shoe orthotics.

No PA req'd - *QPAD*

Educ mbr on balance billing


300

The reason why CL 162225078301 denied.

What is: Rebill w/ alternative/appropriate HCPCS/CPT code?
300
True or false: No referral is required for TMJ Splint Services.
What is TRUE?
400
The provider relations rep responsible for Crook County.
Who is Robin Solomon?
400

The steps you take to get to the medical policies on Provlink.

What are: QMM tab - Medical Policies and Criteria - Medical Policies and Criteria - :)
400

The maternity in-network benefit quote for MBR ID 100506767-00.

What are:

Prenatal Visits: CIF, DED waived

Delivery/Postnatal Visits: $2500 DED, 30% COINS up to $7350 OOPM

Inpatient Hospital/Facility Services: $2500 DED, 30% COINS up to $7350 OOPM

Routine Newborn Nursery Care: $2500 DED (newborn's ded), 30% COINS up to $7350 OOPM

400

The reason why CL 170750128100 denied.

What is: Provider Billing/Coding Error?

*BONUS: What specifically is causing the error?

*Line 1 TOS indicates: Rebill w/ more specific Revenue Code (claim notes also state this)

400
Whether or not PA P226731 was approved for in-network benefits for MBR ID 113029478-00 for speech therapy to be done at OHSU.
What is: YES, approved for in-network benefits?
500

The Timely Filing Requirement for an initial submission on a claim.

*BONUS: What is the timely filing requirement for a corrected claim for Oregon-based plans?

What is 12 months from the DOS?

*BONUS: What is 18 months from the processed date?

500

The steps you take to get to the payment policies on Provlink.

What are: Home page - Resources - Policies - Coding

500
The in-network acupuncture benefit quote for MBR ID 100962390-00.

What is:

Acupuncture-$25 CP, ded waived, up to $7350 OOPM, combined limit of 3 visits with CHIRO.

Alt Care OV-$25 CP, ded waived, up to $7350 OOPM

Xrays/Labs-30% COINS, ded waived, up to $7350 OOPM

Outpatient Rehab-DED $2500, 30% COINS, up to $7350 OOPM, with a combined limit between PT/OT/ST of 30 visits PCY; up to 30 additional visits per specified condition.

500

The reason why CL 170045997600 denied.

What is: Deny - Non Plan Provider?

Member is on a personal option plan - no OON benefits

500

True or False: The following claim processed correctly.

CL 171033728600 was for a specialist OV and processed in-network for a connect member, however no referral was on file.

*BONUS: Why or why not?

What is TRUE.

*BONUS: Because the member's medical home is PMG, and the specialist is also at a PMG clinic and therefore is seamless access and no referrals are required for seamless access clinics.

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