Verifying Eligibility
Name 3 of the 7 different types of plans offered by MassHealth.
Standard
CommonHealth
CarePlus
Family Assistance
ConnectorCare
Premium Assistance
SafetyNet/Limited
Name the website that we use to check eligibility for almost any payer.
Experian
Name the basic info you need before going into the EMR.
Provider Name
DOS
What was the procedure
Name the payers that require a modifier be added to each charge on behavioral health claims.
MBHP
Carelon
Recently there was an occurrence of something that only happens every 4 years. What was it?
Leap Year-February 29th.
Name the behavioral health carve out plan payer for Cigna.
Evernorth
Name the people you email when you place a file in the Printing folder that needs to be printed and mailed out.
Anita Fetherman
Anabolena Jordan
CC-Kristina and Bethany
Explain why you would receive a denial w/ a CARC code of PR-16-Lacks information submission error and a RARC code N4-Missing/incomplete/invalid prior Insurance Carrier EOB.
The payer believes they are secondary and they need the primary carrier's EOB to correctly process the claim.
Name the list that tells you a what payers a provider is in network and where can you find that information.
Payer Participation Lists and they can be found in Teams under the Teams Icon
What is one fun fact about you?
Thanks for sharing!
True or False- When finding other payer information on Medicare's portal. You do not have to check eligibility on that new payer's portal or Experian.
False-You always need to check eligibility for the new payer you found to make sure they agree. Otherwise, the claim will be denied and you back where you started.
When splitting insurance payers due to a change in coverage what date do you enter as the effective date in Expanse? Is it the DOS or the date the policy became effective?
The date the policy became effective.
On the Medicare Portal- which button do you click to submit a corrected claim? Would it be Initiate a Clerical Error Reopening or Initiate Redetermination
Initiate a Clerical Error Reopening
Name the only payers that we cannot bill charges for mid-level providers?
Medicaid
Medicaid PCC
What is Medicare?
Government funded insurance for Seniors and people with disabilities.
In mPower, where do you check to see what AR Flags you need to action when documenting the work you did in Expanse.
The little red flag icon-hover over it and it will show you which ones to action.
Where do you go in Expanse to move a balance to a different bucket?
Process TXNs tab then Edit Balance at the bottom.
In the EMR, how can you see more reports for other DOS or providers? Ex. An Operative Report from 2023
By clicking on the little plus sign in the More Reports column
What do you change the charge amount to when a claim for a Mid-Level Provider is paid by Medicaid PCC?
$.01
What does EMR stand for?
Electronic Medical Records
You have a CARC 27 denial-Expenses incurred after coverage terminated from TuftsMCD. You check eligibility on the MassHealth portal and it says the patient had CarePlus on the DOS. Who do you bill?
If when you click on the date range next to CarePlus and it shows a different MCO listed you would check eligibility for that payer. If active, you would bill that payer. If no MCO is listed, you would bill MCD (MassHealth) using their policy number starting with 100.
You receive a denial PR-108-Rent/purchase guidelines were not met from BCBS. What are they really looking for?
EOB from the primary payer.
You need to send medical records for a knee replacement. The charges are from an assistant surgeon. What report would you send?
The Operative report that was created by the lead surgeon. Assistant surgeons do not write a separate report.
How do you refund a payment made to a mid-level provider on the Medicaid portal?
Find the claim on the portal and click on the ICN you want to refund. Click Void at the bottom. **Remember, when you void the claim on the portal you are voiding everything on the claim. If you need to refund just one line, then you would do a corrected claim.
What is a deductible?
The amount a patient needs to pay before their insurance benefits begin.