Blue
If you have a fax with more than one member, what should you do?
Separate the fax( hit save, and select custom pages and save each request separately)
Save original fax to the unable to process folder as Multi-Member
Shell each request
In ABA authorizations, who is the Treating Provider and who is the Requesting Provider?
BCBA-Treating
AGENCY-Requesting
If a Provider is on the phone and states they want to schedule a Peer to Peer, what should you do?
New Process: Reach out to the person assigned to see if they can take the call. If not either reach out to someone else on the Peer to Peer team or ask in the chat if someone is available to schedule the Peer to Peer.
If a member has an approved H0006 on file and a request for H0023 comes in what should be done?
If Provider is no longer providing the service discharge that auth and approve the new request. If no response from provider, add your note and assign to DeNeshia as well as sending a Teams message.
A member calls with a provider on the line and is requesting to discharge from a services with another provider. What should you do?
Inquire if you can call member back to have a private conversation to ensure the member is using their right to choose.
True or False: Staff should check their Worklist everyday to ensure they have not accidentally assigned authorizations to themselves
True over the past few weeks authorizations have been shelled by Temps and assigned to Patient Services Coordinators and Authorization Secretaries, some have cleared their worklist while others have some still lingering.
If a Provider calls and requests to make changes to the Provider can we do this?
If you enter the NPI/Tax ID and a different Provider populates, then yes.
If a provider request to change in the ABA auth the requesting provider to the BCBA and the treating provider to the treating provider, the answer is no. We cannot do this. They will need to speak with Provider Relations to ensure they are billing accurately.
A request is submitted for BH IP for a Medicare Member do you shell it or send it to another fax queue?
Behavioral Health 9 codes (except ABA) and IP can be processed under the Medicare LOB.
What should you do when a member shows as inactive in Jiva?
Check QNXT, if member inactive check DMAS. If member is active reach out to Team Coordinator as an email needs to be sent.
If in QNXT member is active, reach out to Team Coordinator as an email needs to be sent.
Can our team change the dates of service or units in authorizations that have been processed by the Reviewer?
No, once a Reviewer has processed the authorization the Reviewer has to make changes.
When is it okay to void an authorization?
When the provider has requested to retract an authorization?
If its a clear duplicate, same service code, same dates, same units, and same provider.
When should a document be sent to the Appeals fax queue?
What are some things you look for when trying to determine if the request is a CSR, Duplicate or Discharge.
Provider has to be the same
Start date is the same
Last Name_First Name_Provider Name_Date Received
Provider is on the phone asking specific questions about why an authorization was denied (ie, medical necessity criteria, service limitations, DMAS manual questions), what should you do?
Transfer to the UM Reviewer line.