Validation
Authorizations
Manual Pricing
Ambulatory Surgery
Common Hold Codes
100

WHEN VALIDATING THE MEMBER'S INFORMATION, A MATCH IS REQUIRED ON HOW MANY DEMOGRPAHICS WITHIN ME1014?

AT LEAST 2

100

TRUE OR FALSE: WITH THE EXCEPTION OF EMERGENT SERVICES, OUT-OF-NETWORK PROVIDERS ALWAYS REQUIRE AN AUTHORIZATION

FALSE: THERE ARE SEVERAL AUTHORIZATION EXCEPTIONS FOR OON PROVIDERS SUCH AS ANESTHESIOLOGY AND PROFESSIONAL SERVICES IN POS 21

100

WHICH HOLD CODE DO YOU APPLY WHEN YOU MANUALLY PRICE A CLAIM TO PAY NEGOTIATED RATES?

HOLD CODE 8A

100

WHICH HOLD CODE(S) INDICATES PAS CODE PRICING AND DIRECTS US TO AMBULATORY SURGERY MANUAL?

HOLD CODE A4

100

RESTRICTED RECIPIENT- REVIEW ME1083

9R

200

NAME ONE (1) EXCEPTION OR EXCLUSION TO HOLD CODE 9R FOR MEMBERS WHO ARE LIMITED TO SEEING THEIR PCP, MEMBERS OF PCP'S GROUP, AND OTHER PROVIDERS REFERRED BY THE PCP

- AUTH ON FILE

- P-ORG 85 - COVERING PHYSICIAN W/ SAME ADDRESS AS PCP

- EMERGENT AND URGENT SERVICES (POS 20, 23)

- DIALYSIS (BENEFIT CODE: DIA)

- HOME HEALTH (BENEFIT CODE: HLH)

- TRANSITIONAL CARE FOR SPECIFIC PROVIDERS

- NON-EMERGENT TRANSPORTATION FOR LI MEMBERS

- WALK WITH ME PROVIDERS

- PROVIDER: THE BRIDGE

- PROVIDER: HARLEM UNITED COMMUNITY AIDS CENTER

- CLAIM BILLS RATE CODE FROM TABLE

200

WHICH REASON CODE DO YOU ADD TO LINE 1 WHEN WAIVING THE AUTHORIZATION REQUIREMENT FOR PLAN-DIRECTED CARE?

AOPD

200

WHAT DOES HOLD CODE BT MEAN?

[MANUFACTURER'S] INVOICE REQUIRED

200

WHICH MHS SCREEN DO YOU GO TO IN ORDER TO SELECT "CASE PRICING" AND ENTER THE PAS (SUB)CODE

CL1035

200

NO FEE SCHEDULE FOUND FOR SRVC

42

300

WHEN VALIDATING PROVIDER DATA IN MHS, WHAT IS THE ONE FIELD THAT MUST MATCH THE CLAIM IMAGE?

TAX ID (TIN)

300

WHICH MODIFIER INDICATES PHYSICAL THERAPY SERVICES?

MODIFIER GP

300

TRUE OR FALSE: WHEN HOLD CODE [VL] FIRES AND THERE ARE NEGOTIATED RATES ON FILE, YOU MUST MULTIPLY THE NEGOTIATED RATE x UNITS BILLED

FALSE - NEGOTIATED RATES MAY VARY; SOME ARE PER UNIT BUT OTHERS ARE PER HOUR, PER DIEM/DAY, ETC. 

WE MUST REVIEW THE RATES LISTED ON THE AUTH AND COMPARE TO UNIT OF MEASUREMENT OF PROCEDURE CODE

300
ON CLAIMS FOR MULTIPLE PROCEDURES, HOW MANY PAS CODES ARE PAYABLE PER DATE OF SERVICE?

UP TO 3

300
CHECK AUTH NOTES FOR INFO

VL

400

IN THE EVENT OF A COMPLETE MISMATCH ON MEMBER INFORMATION, WHICH HOLD CODE WOULD BE USED TO DENY THE CLAIM?

HOLD CODE CA [INVALID CIN# FR MEMBER'S NAME]

400

WHICH TWO PLACE OF SERVICE CODES NEVER REQUIRE AUTHORIZATION?

POS 23 and 20

400

NAME 1 MODIFIER THAT IMPACTS PRICING

26, 50, 51, 52, 53, 54, 55, 56, 62, 73, 74, 78, 80, 81, 82, AD, AS, GM, QK, QX, QY, RR, TC, UE

400

WHAT IS THE DEFAULT DENTAL PAS CODE?

D3043A

400

AUTHORIZED DAYS EXCEEDED

64

500

IF YOUR CLAIM GENERATES HOLD CODE [T9], WHAT CLAIM FIELD MUST YOU REVIEW? 


DIAGNOSIS CODES

THESE SERVICES ARE ONLY COVERED IF THEY ARE BILLED WITH AN ASTHMA DIAGNOSIS (J45.XX)

500

TRUE OR FALSE: HOLD CODE VL ALWAYS MEANS THERE ARE NEGOTIATED RATES ON FILE

FALSE - HOLD CODE VL IS ALSO USED ON DME CLAIMS TO IDENTIFY RENTALS VS PURCHASE AGREEMENTS

500

"HOLD CODE [QV] IS GENERATED WHENEVER THE MATERNITY ANTEPARTUM CODES ____ & ____ ARE BILLED"

59425 AND 59426

500

LIST 3 AMBULATORY SURGERY REVENUE CODES

360, 361, 369, 481, 490, 499, 750, 759, 760, 762, 769, 790, 799

500

AGE INVALID FOR DIAGNOSIS

34

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