Acronyms
MTE
Medicare Set-Aside Temporarily Exhausted
What is the expected turn around time for authorizations or quote reviews?
What is one business day?
This remark code is applied when a service is not typically allowed by Medicare.
What is NMA (non Medicare-allowable)?
When a refund check is received, reviewed, and deemed to be invalid, this document is created before requesting the check be mailed back to provider.
What is the Return of Refund Check Letter?
What team handles member and CMS notifications of exhaustions?
What is Member Services?
MSP
Medicare Secondary Payer (compliance or act)
Name 3 commonly requested items that are instant denials from MSA accounts.
What are home modifications, disposable supplies, and home-health aides (or any other combination from the reference sheet)?
These types of accounts always show a $0.00 accrued balance in FM - this is not an error or indication of an exhaustion.
What are trust and SAK accounts?
This remark code is used when approving payment for a claim where a pricing error is corrected.
What is AP (additional payment)?
This type of account exhaustion is used when no further fund replenishment is expected.
What is Permanent Exhaustion?
TDR
Trust Disbursement Request
This system field in the Quote Review screen is used to document the payment methodology applied when determining an approved amount.
What is the Calc Method (drop box)?
This three digit code is used to determine the specific place of service for facility billing.
What is UB-04 box 4 (type of bill)?
This response is given if an account was exhausted for the billed date of service.
These three steps must be done for every temporary exhaustion.
What are:
*Updated accounts-exhaustion tab in FM.
*Emailed notification to PBM (WAM).
*Accrued activity report attached.
BCRC
Benefits Coordination and Recovery Center
This supplemental website can be used to evaluate if a piece of durable medical equipment fits coverage guidelines.
What is PalmettoGBA (or Optum)?
When adjudicating a claim for a liability case, providers are paid at this percentile using the UCR CompIQ calculator.
What is the 60th percentile?
For non-claim medical documentation (such as a provider letter or referral), the claimant's note must include these five elements.
What are: type of document received; date of service or date of document; summary of information provided; impact on future claims (if applicable), and indication of any further action needed or taken.
This document determines patient responsibility and must be attached before denying a claim balance to be filed to the member.
What is the Medicare EOB (or other payer EOB)?
NGHP
Non-Group Health Plan
These are the at least three ways an authorization or quote request could be processed and the key difference(s) to tell which one is used.
What are benefits explanation letter, quote review, or BCN (payable); was pricing submitted and is this a preferred vendor?
For an inpatient facility claim priced by MFS, this field from the UB-04 Box 71 is required. If it is blank, the claim cannot be processed as inpatient.
What is the PPS/DRG code?
These determinations cannot be appealed (or will receive the same response as the previous appeal, regardless of provider rationale)?
What is exhaustion of funds and not Medicare allowable (for MSA)?
This account type is able to pay claims back to the original settlement date so long as all other guidelines are met and funding is available.
What is a Medical Custodial Account (MCA)?