WHEN VALIDATING THE MEMBER'S INFORMATION, A MATCH IS REQUIRED ON HOW MANY DEMOGRPAHICS WITHIN ME1014?
AT LEAST 2
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
WHICH HOLD CODE DO YOU APPLY WHEN YOU MANUALLY PRICE A CLAIM TO PAY NEGOTIATED RATES?
HOLD CODE 8A
WHICH HOLD CODE(S) INDICATES PAS CODE PRICING AND DIRECTS US TO AMBULATORY SURGERY MANUAL?
HOLD CODE A4
RESTRICTED RECIPIENT- REVIEW ME1083
9R
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
WHICH REASON CODE DO YOU ADD TO LINE 1 WHEN WAIVING THE AUTHORIZATION REQUIREMENT FOR PLAN-DIRECTED CARE?
AOPD
WHAT DOES HOLD CODE BT MEAN?
[MANUFACTURER'S] INVOICE REQUIRED
WHICH MHS SCREEN DO YOU GO TO IN ORDER TO SELECT "CASE PRICING" AND ENTER THE PAS (SUB)CODE
CL1035
NO FEE SCHEDULE FOUND FOR SRVC
42
WHEN VALIDATING PROVIDER DATA IN MHS, WHAT IS THE ONE FIELD THAT MUST MATCH THE CLAIM IMAGE?
TAX ID (TIN)
WHICH MODIFIER INDICATES PHYSICAL THERAPY SERVICES?
MODIFIER GP
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
UP TO 3
VL
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]
WHICH TWO PLACE OF SERVICE CODES NEVER REQUIRE AUTHORIZATION?
POS 23 and 20
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
WHAT IS THE DEFAULT DENTAL PAS CODE?
D3043A
AUTHORIZED DAYS EXCEEDED
64
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)
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
"HOLD CODE [QV] IS GENERATED WHENEVER THE MATERNITY ANTEPARTUM CODES ____ & ____ ARE BILLED"
59425 AND 59426
LIST 3 AMBULATORY SURGERY REVENUE CODES
360, 361, 369, 481, 490, 499, 750, 759, 760, 762, 769, 790, 799
AGE INVALID FOR DIAGNOSIS
34