KMS
The payer ID for ZirMed.
What is PHP01?
The three places online you can find the Prior Authorization Request Form.
What is KMS, Provlink and the PHP External Website.
The benefit you'd quote for a Kadlec Medical Center member, for a tubal ligation with an in-network provider and at an in-network facility.
*BONUS: What benefits would you quote off the benefit summary if they went out-of-network?
What is "Covered in Full"?
*BONUS: Surgery/anesthesia (prof) and Outpatient Surgery (facility)
The reason why CL # 180256130800 denied.
What is "member not eligible"?
This happens when a choice member sees a specialist without a referral on file.
What is "the claim processes out-of-network"?
What modifier NU means.
What is DME Purchase?
The steps a member takes to find information about their benefits.
What are: PHP Internet - Members - Understanding plans and benefits
The vasectomy benefit quote for MBR ID 100360213-00.
What is "not covered"?
The reason why CL # 180373149800 denied.
What is "Service Not Authorized, Provider Resp"?
What has to happen after we received a retro referral on file after a claim has processed out-of-network due to referral violation.
What is "the claim needs to be reprocessed with the retro referral attached"?
What POS 42 stands for.
What is Ambulance - Air or Water?
The steps a member takes to find the member reimbursement form to fill out and submit to PHP.
What are: PHP Internet - Members - Forms - Claims: Medical claim form
The out-of-network benefit quote for HCPC code L3000 for MBR ID 100758985-00 (as if the member were calling - include all components you'd go over with a member.)
What is:
30% coinsurance (ded waived on all foot orthotics) up to $4000 OOPM with no limit.
No PA req'd - *QPAD*
Educ mbr on balance billing
The reason why CL# 173134729900 denied.
What is "Bill Through Local Blue Plan - Prov Resp"?
*BONUS: What address should the provider resubmit the claim to?
True or false: No referral is required for TMJ Splint Services.
What is TRUE?
The provider relations rep responsible for Crook County.
Who is Robin Solomon?
The steps you take to get to the medical policies on Provlink.
What are: Resources > Policies > Medical Policy
The in-network maternity benefit quote for MBR ID 100869984-00. (Delivering at Providence St. Vincent)
What are:
Prenatal Visits: CIF, DED waived
Delivery/Postnatal Visits: CIF, DED waived
Labs/Ultrasounds:$1150 DED, 20% coinsurance up to $3300 OOPM
Inpatient Hospital/Facility Services: $1150 DED, 10% coinsurance, up to $3300 OOPM
Routine Newborn Nursery Care: 10% coinsurance, deductible waived, up to $3300 OOPM
The reason why CL # 180253419500 denied.
What is "Deny Procedure, rebill w/ alternative HCPCS/CPT"?
Whether or not PA P269153 was approved for in-network benefits for MBR ID 113223077-00 for surgery with Dr. Hans Carlson.
What is NO. Partial approval - approved at OON rate for both provider and facility.
The Timely Filing Requirement for an initial submission on a claim.
*BONUS: What is the timely filing requirement for a corrected claim for Oregon-based plans?
What is 12 months from the DOS?
*BONUS: What is 18 months from the processed date?
The steps you take to get to the payment policies on Provlink.
What are: Resources > Policies > Coding
The in-network acupuncture benefit quote for MBR ID 100962390-00. (Tier 2 provider)
What is:
OV to Alt Care Provider: $3000 FAM DED, 20% coinsurance, up to $6000 FAM OOPM
Acupuncture: $3000 FAM DED, 20% coinsurance, up to $6000 FAM OOPM, with a limit of 12 visits PCY combined w/ chiro
Xrays: $3000 FAM DED, 20% coinsurance, up to $6000 FAM OOPM
OP Rehab: $3000 FAM DED, 20% coinsurance, up to $6000 FAM OOPM
The reason why CL # 173326028300 denied.
What is "Dollar Maximum For This Benefit Met"?
*BONUS: WHAT claim was this benefit limit met on?
True or False: The following claim processed correctly.
CL # 163075890600 was for a PCP OVF but processed out-of-network, when the provider was actually IN-network.
What is TRUE. The member did not have a medical home listed on file, therefore the claim processed out-of-network.