DME
Which benefit a glucose monitor falls to for a SAIF member. (DME or diabetic supplies)
What is DME?
The department at PHP responsible for reviewing submitted prior authorization requests.
What is HCS?
What type of DME L codes are for.
What are prosthetics and orthotics?
Using member 10013459500, please quote the tier 1 benefit for a medical office visit with a PCP.
What is:
Ded waived
$20 CP up to $3300 OOP Max ($0 met)
Your favorite type of food.
(insert favorite type of food here)
The location code billed indicating a provider's office.
What is POS 11?
Using PEBB, whether or not a PA is required for CPT 42226.
What is yes?
Whether or not E0170 is a payable code (Office or DME vendor).
What is no?
BONUS Bragging Points: Who does it deny to?
Using member 11281169400, please quote the in network benefit for a Specialist office visit with labs.
What is:
$250 Deductible
$10 CP up to $1500 OOP Max
The name of a form someone can fill out to give access to their account to someone else.
What is a consent form?
The location code billed indicating the member's home.
What is POS 12?
Whether or not a PA is required for 95869.
What is no?
(disclaimer needed) This is not a guarantee of payment, and all services are subject to medical necessity, eligibility at the time of service, and cannot be cosmetic, experimental or investigational and are subject to plan exclusions.
Whether or not a PA is required for code A4290.
What is yes?
Using member 100676398-00, please quote the Speech Therapy benefit for an out of network provider.
What is:
$500 Ded, 30% Coins up to $4000 OOP Max
60 visits PCY - PT/OT/ST combined
Nothing met towards Ded and OOP max, all 60 visits available
Whether or not the PA/Ref P267458 was approved or denied for member 100212233-00.
What is disallowed/denied?
BONUS: Why? (Hint: Click notes)
Using PHS OR, this is the vendor responsible for DME distribution in Oregon and SW Washington.
What is Providence Home Services?
The amount of time that HCS has to review prior authorization requests.
What is 48 business hours?
Whether or not a PA is required for code J0606.
What is no? (As of 04/01/18)
For member 113263114-00, please quote the benefit for HCPCS E0118 from Providence Home Services.
What is a $350 Ded, 20% Coins, up to the $2350 OOP Max, (check accums). No PA required and the code is payable when the item is obtained through Prov Home Svcs. *QPAD*
The CPT/HCPCS code approved on PA/Ref 180021178 for member 112801496-00
What is the HPCPS code J1745?
Whether or not Evergreen Prosthetics and Orthotics (Oregon City) is in network or out of network for MBR ID 112904686-00.
What is yes? (Providence Home Services subcontractor)
For PHS Premera providers in Montana, these are the options available to them if one of their claims denies because they failed to submit a prior authorization.
What is write it off, submit a reconsideration and/or balance bill the member.
Whether or not a member can obtain code E2326 from a provider's office or not.
What is no?
BONUS Bragging Points: Who does it deny to?
For member 112966601-01, please quote the tier 1 benefit for a diagnostic mammogram with an ultrasound.
What is: $325 deductible, covered in full for the facility, $325 deductible, 20% coinsurance up to the OOP max of $3,000 for the professional portion. This is for the diagnostic mammogram and the ultrasound.
Where in KMS we find the list of Place of Service codes (POS) and their definitions.
Left navigation bar --> Definitions --> Facets Codes and Claim Codes --> Medical or CMS 1500 Codes --> Place of Service Codes