Authorizations
When dashboard returns Auth Not Required with Plan-Directed Care exception, what should you do next?
Perform traditional search to find another valid auth/exception. If one is not found, apply JN
If an anesthesia claim missing ____, deny by applying EZ.
If an anesthesia claim missing anesthesia time, deny by applying EZ.
What type of services does Hold Code SY generate on?
PT Services
SY [Pay PT Services Once Per Clm]
How do you price ON Facility claims with ER visit?
[Pend for] APG Pricing
In RF1031, how do you open the Service Class Mapping Window?
Shift + F4
What are the two most common types of Global Authorizations?
Which Hold Code do you add to a Newborn claim when you do not find CIN# and need to send a SF to Enrollment?
GH [Newborn - Ref to Enrollment]
TRUE OR FALSE
If BV or 42 generates on a line, but the line has a system-applied denial code, pricing is not required - you should V&E the BV/42
FALSE
If BV or 42 generates on a line, it should still be addressed and priced, even if the line is going to deny.
What is the POS code for Freestanding Dialysis Center?
Name a Hold Code that denies a claim for timely filing
26 - Most Common
SZ, NL, NX, ZO
Reminder: If you have any of these hold codes on a Corrected Claim, we should pend for HF to review
Pathology claims can be billed (up to) __ days after a surgical procedure.
Pathology claims can be billed (up to) 14 days after a surgical procedure.
What does Hold Code W8 mean?
Consent Form Required
Which day(s) should we pend claims with unverified D0 and all Source fee IDs on every line?
Tuesdays
TRUE OR FALSE
If a claim an Am Surg claim has one surgical procedure and it is generating Hold Codes A4 and 02, and there is no valid auth on file, we apply JN to the PAS Code line (D30XX line)
FALSE
When a surgery is not payable, we do not create a PAS Code line.
Oxford Health Medicare Risk is an example of a ____ OI Plan.
(Original Medicare, Medicare Advantage, or Commercial)
Oxford Health Medicare Risk is an example of a Medicare Advantage OI Plan.
DOUBLE JEOPARDY
For Bonus Points:
Name a Medicare Advantage plan we might see in ME1013 that does not have "Medicare" in the nameName 4 places where you might find a valid Authorization Number.
Auth Dashboard, Pega, Evicore, MHS CL1011, Claim Image (CL1038/CL1035)
When reviewing a 9R claim and the rendering provider has the same p-org as the member's PCP, which screen do you go to in order to review the provider's level?
PR1033
DOUBLE JEOPARDY
For Bonus Points:
If the provider is Level ___, we verify and adjudicate the 9R to allow payment.
Name 3 Northwell p-orgs
1X, 1Y, 11,2F, 2H, 24, 27, 32, 33, 34 71, 72, 73, 75
Which codes are used to identify HARP/PWP claims?
Value Codes
DOUBLE JEOPARDY
For Bonus Points:
What does PWP stand for?
When reviewing a duplicate claim from a provider or the same specialty, name 3 modifiers that would indicate the claim should be marked NOT A DUPLICATE
24, 25, 26, 27, 50, 51, 59, 62, 76, 77, 80, 81, 82, AS
GO, GP, LC, LD, LT, RC, RT, QY, QX
E1-E4, FA, F1-F9, U1, U2, U6, U7, TA, T1-9
Name 2 services that require an exact service code match (i.e. upcoding/downcoding does NOT apply)
Skilled Nursing Facility, Home Health, DME
DOUBLE JEOPARDY
For Bonus Points:
List 2 Home Health Benefit IDs
Name two reasons why Hold Code 36 might generate
1. Data Entry
2. Service Code Billed is not Allowed in the Reported POS
3. Incorrect member ID for the DOS
4. Claim Outside of Member Eff Date
5. QI Category 2 CPT Codes
6. Not reimbursed by HF
7. Requires Current CPT-4 SVC Code
8. Procedure Code Deleted
9. Invalid Serv/Mod Combo
10. Dummy Group or Package in MHS
HES, GHL, HSC, GHV, GHY, GHK, GHD, GHR, GHT, GHJ, GHX, GHF
Name 3 Ambulatory Surgery Revenue Codes
360, 361, 369, 481, 490, 499, 750, 759, 760, 762, 769, 790, 799
What are our three quality metrics we're measured by, and what are their target goals?
Payment Accuracy - 98%
Procedural Accuracy - 95%
Financial Accuracy - 99%