Case Updates
When DX code needs to be added after finalization do we need a new case?
No, you may send a msg to NR on case.
When member is showing as default payer do we send case to review?
No, case should be placed on hold(Request for additional info)
What information are we allowed to leave on unsecured VM?
CEN number and callback
SCA
Single Case Agreement
Do we handle Cardiac for NV
No
Are we allowed to update the facility on an approved case?
Yes, as long as facility is INN
When we receive an intake form and no clinicals are attached after making 1st attempt do we send to review?
No, you must make second attempt then send case to review.
If you receive a call from the health plan what pieces of information do you need to verify HIPAA?
Member name, member ID, and DOB
WLP
Weight Loss Plan
Can A PSCR be done for WC Medicare?
No, they would need to reach out to the HP for further assistance.
Can you change DOS for inpatient procedure if approved in WC KY- Medicaid?
Yes, if within 60 days and the DOS has not passed and send email to case updates
When an intake is completed over the phone and 1st attempt and 2nd attempt have been done but dx code is missing do we send case to review?
No, case is to be placed on hold until dx code is receieved
A caller states he is from the provider’s office. He is able verify member name, DOB and member ID, TIN however this case is from 2021 and provider TIN does not match this case. What information can be released to the caller?
None!
TF
Task Force
What is the TAT for 1st level expedited appeal for TX?
It is up to 72hrs.
Can a provider be update on an already approved case?
Yes, as long as the TIN # is the same and provider INN.
If case is on hold in NR and new clinicals are attached do we send case to resume review?
No
How will you ensure you do not miss HIPAA when getting interrupted by the caller during the call?
Any answer is a great answer as long as HIPAA has been verified!! Lol
TAT
Turn Around Time
What is the number to HR?
407-794-6918
Are we allowed to send/request authorization be sent to the facility?
No, unless the facility initiated the request
If the facility/PO is showing OON do we send case to review?
Yes!
If a provider office/facility can verify 3 pieces of information (name, DOB, and member ID), What can be used to substitute for the TIN/NPI for facility/practice?
Nothing, you need the TIN/NPI to verify HIPAA!
DOS
Date Of Service
What is the timeframe that PO can submit a retro for FID member for Cardiac?
14 business after procedure has been done.