Basic Questions
What is Guidehealth?
What provider type should always be selected in availity?
Professional
What pieces of information is required to verify HIPAA before releasing PHI?
First & last name, date of birth, insurance ID number.
Which key brings up the ribbon at the bottom of the ECI screen?
Backslash
These medical groups are capitated.
AMITA/Ascension, University Of Chicago.
What is an HMO?
A type of health insurance plan that requires members to use a network of doctors and hospitals. Members often need referrals from a PCP to see specialists.
A green box after submitting an eligibility request means?
Member is active with BCBS.
Verbal Consent is valid for how long?
Only for one-time use during the call.
What option on the ribbon should you select in your first step updating a PCP?
Utilities
PCP assignments for capitated IPA’s can only be made effective on this day.
The 1st of the month.
What medical groups do we manage? List ALL!
AMITA/Ascension, Endeavor Health, Northwestern, Progress Health, Physicians Care Network, Powers Health Partners, Pathways and Behavior Healthcare Partners.
How far back can you backdate the "as of date" for BCBS members in Availity?
1 year
If the caller is not on the policy, what must be obtained before you can speak with them?
Verbal consent from the policy holder.
This status means the policyholder is not with the medical group, but a dependent is.
Pended.
When submitting a Jira ticket for PCP change, what must be attached?
Availity screen shot, and PCP from portal.
What is a Netcode?
A code that identifies whether a provider is in network with a medical group.
What key detail should you look for to determine if the member is a part of our medical group?
Plan network ID.
What is the main purpose of HIPAA?
To protect patient information.
To locate a provider or member account, what is needed?
First name and last name or email that they registered with.
The only specialties that can be assigned as PCP's are these 4.
Family practice, Primary Care, Internal Medicine, and Pediatrics.
What criteria must be met for HMO coverage?
PCP referral, services need to be in network.
When checking eligibility of a twin, what is the best practice to ensure you can locate the member?
Using the Patient ID, DOB, and first name.
Adolescent member (age 12-17) must give this before you can release any Behavioral Health information to caller.
Direct Consent (verbal or PHI form)
List ALL the functions of our website?
Provider finder, eligibility, PCP updates, claims, authorizations, submitting a ticket.
If a provider is listed as not accepting new patients, what must the agent do before assigning a member?
Contact office to confirm. Document who you spoke with.