COB
The definition of the Post-Mandate methodology for COB.
What is: In this method of payment, the goal is to make the provider financially whole, meaning regardless of which insurance company pays first, the provider will be reimbursed at the highest contracted rate. In the past, the providers felt as though they were being penalized financially based on which insurance company is in the primary position and their contracted rate with them, so they lobbied for a change and won. The result of their win means that if there is a cost difference between the contracted rates from the primary and secondary insurance company, and the secondary insurance rate is higher, then the secondary coverage in some cases may pay out more than the member responsibility owed.
The vendor we utilize to review prior authorizations related to high tech imaging requests.
Who is AIM? (American Imaging Management)
The payer ID that Dr. Melinda Marks (Jefferson St, Boise, ID) would send a claim to for MBR ID 100129262-00. Her clearing house is ZirMed.
What is: PHP01?
The definition of a clinical edit.
What is: System denials due to incorrect coding and bundling and payment of certain CPT codes?
What it means if a rider is black in the benefit summary look up tool.
What is benefits are embedded in the medical policy/benefits?
The 4 benefits/risks of being double covered.
What are:
•How much are the monthly premiums of my primary and secondary insurance?
•What does my primary coverage look like?
•How often do I use medical insurance?
•How do we coordinate benefits in the secondary?
The reason why CL 150363954100 denied.
What is: BAM - No AIM authorization
The tab within Claims Inquiry that houses a second disallow explanation applied to a claim.
What is the Disallowed Amounts Tab?
The clinical edit applied to CL # 180296208800.
What is: z60 - Not a Primary Diagnosis Code
The grace period length of time that members eligible for APTC have to pay their premiums before their plan is terminated.
What is 90 days?
Whether or not providers need to submit their claim twice to PHP for a dual PHP member.
What is no? The provider only needs to send the claim to the primary account. PHP will process the claim under the primary account's benefits, then transfer the claim to the secondary account and process the claim on the secondary.
The CPT codes approved on PA # 130683826 for MBR ID 113104753 with DOB 08/07/53.
What are: 74176, 74177, 74178, 76376 and 76377.
The address AND fax # where Dr. Charles Pollick (Wilshire Blvd, Los Angeles, CA) would submit a claim for MBR ID 113176539-00.
What is: PO Box 3125 PDX, OR 97208 or 503-574-5940.
The payment policy referenced in the denial for line 2 on CL 172684179400.
What is Payment Policy 13.0?
The department that OPR (Overpayment Recovery aka Refunds) is a sub department of.
What is OFT? (Operation Financial Transactions)
Whether or not a member needs to satisfy their deductible on their secondary account before the secondary insurance pays out on claims.
What is yes?
The reason why CL # 180174170500 did not require a PA for lines 2 and 3 which are high tech imaging.
What is: ER claim? No PA required for services done in the emergency room.
The address, fax # and payer ID where Dr. Peter Albro (7th Ave, Seattle, WA) would submit a claim for MBR ID 113203242-00.
What is:
Attn: FCHN
PO Box 2289
Seattle, WA 98111
Fax: 206-268-6181
Payer ID: 91131
What a provider can do for denial on CL 180666025000.
What is rebill with a more specific diagnosis code?
Whether or not wigs are covered on individual plans.
What is yes? Member must be receiving chemotherapy or radiation therapy for this benefit to apply - 1 wig PCY.
Where a CSR can go in Facets to find out more information about COB information. (No, the answer is not the COB task page...........)
What is Member Notes?
The national network(s) that do not require a PA for high tech imaging.
Who are PHCS/Multiplan, FCHN (MT, AK and Northern ID) and Brightpath.
The TWO places that a CSR can look up explanation code definitions?
What are:
1) KMS > Explanation Codes
2) Facets > Applications Menu - Application Support > Explanation Codes > CSR must scroll through the list to find a specific code
The national network that is not required to submit a Clinical Edit Inquiry form on clinical edit denials.
Who is PHCS/Multiplan?
Whether or not QFC is a preferred pharmacy for any PHP plan.
What is yes?