Surgery
The CPT code range billed for surgeries.
What are 10000-69999?
The type of providers that typically perform colonoscopies.
What are internal medicine doctors or gastroenterologists?
UCR stands for this.
What is Usual, Customary and Reasonable charges? (AKA: Usual and Customary Rates)
The vendor we use to administer our mental health/chemical dependency benefits and process these claims.
What is PBH/Optum?
Our in-network hearing aid provider.
What is Truhearing?
Please quote the benefit for an outpatient surgery at Providence Portland Medical Center.
Use member 100574005-00 if needed
What are surgery; anesthesia (professional/surgeon claim) and outpatient surgery (facility claim)?
The age a member needs to be in order for a colonoscopy to be CIF in-network.
What is 50+?
What UCR is based off of.
What is the average rate of reimbursement for a given service in a given area.
BONUS Bragging Points: Can we know what the UCR will be prior to receiving a claim?
The two claim statuses that apply to a mental health/PBH claim.
What are 81 and 89?
Where members can obtain hearing aids.
Where is an audiologist's office or DME vendor? (Truhearing)
The modifiers that can be billed indicating an assistant surgeon claim.
What are: 80, 81, 82 and AS?
BONUS Bragging Points: What types of providers are NOT covered as an assistant surgeon?
Whether or not a PA is required for a diagnostic colonoscopy being done in an ASC (Ambulatory Surgery Center).
What is yes?
The process in which a non-participating provider bills the member for the difference between the billed amount and our allowed amount.
What is Balance Billing?
BONUS Bragging Points: Can participating providers balance bill a member?
Where a PA request gets sent for services relating to mental/behavioral health or chemical dependency.
Where is PBH?
Whether or not MBR ID 100455674-00 has hearing aid coverage.
What is no? (PERS member)
When quoting surgery benefits, this is one thing we always *ALWAYS* ask for in order to check if a certain something may be required.
What is the CPT code?
The modifier that a provider bills to indicate that a colonoscopy started out preventive, but turned diagnostic.
What is modifier 33?
The company we use to price claims for non-participating ambulatory surgery centers.
What is Date iSight?
The name of the reference document which houses information on difference in financial responsibility between the health plan versus PBH.
What is "Division of Financial Responsibility Between PHP and PBH"?
Information needed to provide to Truhearing when conference calling with a member.
What is:
Member ID/Name
Member in-network DME benefit
Member in-network specialist OV CP
DED/OOPM accumulators along with HA limit and whether it's been used or is still available.
CSI # for reference on both ends
The benefit quote for MBR ID 113059446-00 to get a knee replacement. (In-network)
What are:
Professional: $2500 deductible, $500 CP, then a 30% coinsurance which apply to the $7350 OOPM
Facility: $2500 deductible, 30% coinsurance which applies to the $7350 OOPM.
The colonoscopy benefit for MBR ID 100118505-00.
What is:
Surgery; anesthesia in an office or facility: $100 deductible, 10% coinsurance which applies to the $1200 OOPM.
Outpatient surgery: $100 deductible, 10% coinsurance which applies to the $1200 OOPM.
Labs: 10% coinsurance, deductible waived which applies to the $1200 OOPM.
The name of the process in which we can make exceptions for our members that are being held financially responsible for situations where they were given wrong direction or had little control over.
What is POS - Point of Service Resolution?
BONUS Bragging Points: What's the dollar limit threshold that a CSR has?
Whether or not a covered parent calling on a dependent child who is 15 year old, and they have consent on file with PHP, can PBH talk to the parent about the child.
What is no? The parent must fill out Optum's consent form.
Whether or not MBR ID 112960565-00 is currently eligible for their HA benefit limit.
What is no? The last HA claim on file is 05/26/16, limit is one per ear every 4 calendar years.