CLAIMS
Claim number, status of claim, remit/messages if applicable
What is quoting a claim?
Member name appears in Red
What is Member not active with HPSJ?
Bus Vouchers, Transportation Reimbursement, Lyft Self Serve, Lyft HPSJ, Taxi Self Serve, Taxi HPSJ DAILY DOUBLE!!!!
What is the transportation hierarchy?
Correspondence Ribbon in M360 and UM Module: Auth search, Correspondence Tab
Where a letter for an authorization in Essette be found?
Evidence of Coverage's, EOC
What is the members benefit booklet?
Change HealthCare (2 parts)
What is system used to search for EOB/RA's and paper or EFT payments
Yam Sam and Tonya Anderson
Who are Memberrship/Eligibility team?
Do you have friend/family member outside of the household to transport member?
What is a CSR response to a transportation request?
SJ: 209-762-4702 Stan: 209-762-4703
What are the fax numbers for Inpatient San Joaquin County and Stanislaus County?
Kidney and Corneal transplants
What are transplants that HPSJ covers?
Proper Billing Practices, per the Medi-Cal Guidelines and ADVICE: Proper use of billing modifiers 25 and 29
What are Provider Alerts?
1. Update call log Fax recvd on MM/DD/YY 2. Attached correspondence to Issue 3.Route issue to Membership/Eligibility Queue
What is receiving/submitting a Term Letter?
Member Header: Member Alerts, M360 Ribbon: CM Cases
What are places to check for SWOD Transportation Requests?
Proof that a member cannot be balanced billed from the Provider for the services that were denied by HPSJ
What is a Notice of Action Letter?
In writing with written consent from the member and supporting documents
What is how the Providers submit their Auth Appeals?
Submit with Primary EOB
What is the denial reason on COB claim?
1. Document AEVS message into SBAR 2. Assign call log to Membership/Elig Queue 3. Advise TAT 24 hrs for routine and 1 hr for urgent 4.Status Urgent for expedited requests
What is AEVS shows member is active with HPSJ and QNXT does not?
Trip tracker and Call Log!
What must be completed on every trip/transportation request?
Letter corresponding with the type of auth followed by date format Ex: (A)YYMMDD#####
What is the Essette Authorization Format?
Caller first and last name/relationship/Best contact number or -First name First initial of Last name/office or facility/Best Contact Number - First name and last name(s), HPSJ ID number, CIN number, DOB, Full Mailing Address, Last 4 of SSN, PCP
What is caller verification?
Health Plan of San Joaquin (HPSJ) Paper Processing Facility P.O. Box 211395 Eagan, MN 55121-2195
What is First Time/Corrected Claims address?
Transplant recipient, Long term care, Incorrect re-enrollment (Kaiser)
What are statuses that will cause eligibility to be VOID?
Screen shot of the completed ride
What is Lyft self-serve receipt for Mileage Reimbursement Form?
Auth Summary, M360 Auth Ribbon and Notes Ribbon, Decision Letter
What is where the Dates of Service on an Authorization in Essette can be located?
Gather Members User name, email address, provide information to a member of leadership
What is submitting a Password reset for a member?