Medicaid/Medicare
What does DSNP stand for?
Dual Special Needs Program
What is the turnaround time for a Prior auth?
Standard TAT - 14 Business TAT
Expedited TAT - 72 hours
The form used to score call audits
RISE form
What is APRIL?
A Path to Research, Information & Links
If the case is Inpatient Surgery
Pending for Clinical Review- Elective Inpatient, Outpatient, HHC, DME
On every Medicaid and Medicare call we have to verify
HIPAA
What is the required disclaimer we have to read after creating an auth?
The following reference number acknowledges receipt of your notification or prior authorization request. Please write this number down and refer to it for future inquires. The information in this request does not guarantee payment or represent a treatment decision. Coverage and payment for an item or service may be determined by the member's benefit plan document or the provider's participation agreement with the Healthplan. If you have any questions, please contact us by calling the number on the back of the member's ID card.
On the Intake Tool what do you HAVE to select to look up code(s) for a Medicare/DSNP plan?
DSNP>PNL
What is C&S?
Community and State
ER/Direct Admit/ AIR/ LTAC/ SNF
Pending for Clinical Review- Acute Inpatient
What are the different type of Medicaid plans?
TANF, ABD, CHIP, LTSS, EXPN
Finish this statement; Head in a Bed will...
Always require auth.
What is the system/tool that we can ask prior auth questions?
CHAD/ ChatBot
What is INN and OON?
IN Network and OUT of Network
Outpatient Surgery
Pending For Clinical review- Elective Inpatient, Outpatient, HHC, DME
What system can we look at different plan info that a provider have? Like a phone number or a mailing address
SPIRE, Medicaid Tool
On the Intake Tool; what job aid would I use for any required Scripting
Intake Script
What system can we check to see where a members Medicaid is housed, if we don't service it?
DMEVS
What does HMO stand for?
Health Maintenance Organization
No Prior auth is required script.
"I show the CPT/HCPC code(s) do not have a PA requirement. This does not guarantee coverage. Services are only payable if covered by the health plan and medically necessary. The provider website houses administrative manuals and reimbursement policies which can be used to determine if the services are covered by the health plan"
What does each part Medicare cover?
Part A, Part B, Part C, and Part D
Part A- Inpatient, Skilled Nursing, Hospice, and Home Health Care.
Part B- Covers Medical services that Part A doesn't cover.
Part C- Medicare Advantage
Part D- Prescription Drugs
Where can we locate SOPs and/or Job aids to help with Prior Auths/ Complete anything with Intake?
Intake Job / Intake Tool
CHAD/ChatBot is feed from these systems to get Prior Auth requirements
EPAL/SSG
What is HIPAA?
Health Insurance Portability Act of 1996
NICU/Detained Baby
NICU/ Detained Baby template