Claims
Can we send claims back for review if Allaffia processed it and provider as not sent them the proper documents?
NO! They need to reach out to Allaffia to send that information.
Does the Healthy DC Plan have OON benefits?
NO!!!
How long do we have to document our grievances in crm?
24 hours: Pharmacy Grievances
3 days: For all others
*IF NO EXTRA WORK IS NEEDED, IT SHOULD BE FILED ON YOUR CALL*
2nd Level- 30days from the 1st Level decision dt
Which U.S. city hosts the world’s largest Halloween parade?
New York City!
What can provider do if they do not agree with an AMPS denial?
Appeal, we can not send for review!
What would we be able to send to member for information regarding their benefits?
Handbook!!
If a member is calling because their id card was stolen, do we file a grievance?
NO, we only file if member never received ID and their address was up to date when requested.
What should be included with an appeal that is sent to us on member behalf?
AOR
Which famous magician died on Halloween in 1926
Harry Houdini
0450 is not billable!
Provider should bill 0451 or 0452
Which plan will give member the responsibility to pay if services is not covered by Medstar?
Healthy DC Plan(BHP)
Should we offer grievances if member shows any dissatisfaction with MedStar services?
YES!
Even if members does not ask, they may not know they have the right to file a grievance!
How long does it take for an appeal to show in gc if faxed and how long if it was mailed to us?
FAXED: 48 hours
MAILED: 10-14 business days
What is the name of Dracula’s sidekick?
Renfield
If a provider is not in our system and they want to send us a claim, what should they attach in order for the claim to be proccessed?
W9 form!
so we can add them into our system and process the claim with no delays!
What role does the Authorization Guide and Fee Schedule play when giving benefits?
Fee Schedule: Tells us if code is covered and billable
Auth Guide: Tells us if auth is needed for the covered benefit
If a member is calling to file a grievance on their provider, what should we offer as a resolution?
Offer to send a list of new PCP/Specialist to pick from and change PCP for member if needed.
What is one reason an appeal will not be processed?
Missing Information
It's not an appeal
Duplicate Appeal
Sent to the wrong fax#
Where does bobbing for apples come from?
It dates back to the Romans., where it was believed that the first person to catch an apple would be the next to marry!!!
Provider has multiple claims denying in error for the same reason, can we send for review if more than 5 claims?
YES!!
By changing the *Tertiary Reason to Multiple Claims & Place the date range and denial reason in your notes!
QUICK for MD: Would my lab services be covered with no auth if i go to Medstar Medical Group LLC?
NO! AUTH WOULD BE NEEDED
What kind of Grievances would member be able to follow up on?
Any UNRESOLVED GRIEVANCES
such as:
unable to reach provider office when they have sent member a bill
If the member did not receive an ID card two or more times in a row
If member was unable to receive their medication due to OUR error. (ex: when we didn't process auth within reasonable time, not when provider has not sent auth)
Can provider appeal a claim because they did not get paid what they were supposed to?
NO, a Payment dispute form needs to be sent with supporting documents
In 2023, Travis Gienger nabbed the Guinness World Record for the heaviest pumpkin. How much did it weigh?
2,749 pounds!!!