Benefits
Caid-Physical therapy
non-covered; MO has a Complimentary Alternative Therapy for Chronic Pain Management for members 21 years of age and older only. NOTE: This benefit does not interfere with benefits that are already covered. This is an added benefit.
When does inpatient services require prior authorization?
Always
Medicaid-95810
What is PA required.
What does COB stand for?
Coordination of Benefits
Gap Exception
DSNP
DSNP LPPO-Physical therapy limits
As medically necessary
If a provider is using abusive language, what SOP would you look for?
Contact is Using Abusive or Inappropriate Language - Advocate Contact Handling OneSource
Medicaid-E0266
No PA required
Payor of last resort?
Medicaid
J-codes are covered by the Fee-for-service program
Caid
Caid-Sleep Studies
Covered
Polysomnographic studies may be performed in a facility-based sleep study laboratory Home sleep studies may also be covered and require clinical review.
The criteria that must be met for unattended sleep studies to be a covered service are:
•A home sleep apnea test must be used, with technically adequate devices, to diagnose Obstructive Sleep Apnea (OSA) in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA
•A home sleep apnea test must not be used for general screening of asymptomatic populations
•A home sleep apnea test must not be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation, or suspicion of sleep-related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia
•A home sleep apnea test must not be used to diagnose OSA in children
•When an initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram must be considered to diagnose OSA
What is needed to HIPAA verify a member?
Member ID, first and last name, DOB
DSNP-97110
No PA required
If the member has UHC Commercial plan as primary, which UHC will pay first? Us or commercials.
Commercial
Physical therapy is a non-covered benefit for member's 21 or older.
Caid
DSNP HMO-Cost share for Acupuncture
In Network: 20% coinsurance for each Medicare covered benefit.
OON-not covered
What is the process for a Medicaid member to see an OON dr?
The requesting provider must be INN.
Medicaid-J0585
UHC does not cover J-codes. These are handled through the Fee-for-service program through the state of Missouri.
What can we do if the provider states the member’s COB on file has terminated?
Advise that the member should contact member's services to update the COB information.
Inpatient services require PA
Caid and DSNP
Caid-Doula
Doula is covered for patient education, services performed by a doula/birth worker/ non-physician provider services, family stabilization services & lactation classes.
What do we do if a provider wants to retro an authorization because of inclement weather?
Severe Weather Late Notifications for all lines of business: When there is a service area that is impacted by severe weather, leadership will communicate the time frames when a late notification can be accepted. In these circumstances follow the steps below: 1. Services requiring review on PNL list, excluding administrative approvals: When call, chat or fax is for a late notification due to severe weather, enter a case and document a case note, e.g., Provider indicates late notice due to _________. 2. Services on Administrative Approval PNL List: Approve per standard process on PNL and document a case note, e.g., Provider indicates late notice due to _________.
DSNP-J0585
Yes, PA is required, and must be done through the provider portal.
112625509-What is this member's primary insurance ID number?
950431269
DME over $1000 requires PA
DSNP