Rehab and DME
Panel Status
Preventive & Maternity
Idaho and OOA
Injectables / MH / General Limits and Exclusions
100
Where can we view In Network DME Vendors?
Utility Belt > Vendors
100
What counts as a pre-service call? Name at least 3
Benefits, Code Check, ID Card Request, Preauthorization
100
Are vasectomies covered under the preventive benefits?
No, they are covered under the regular medical benefits. Billed by Place of Service
100
What is a Gap Area?
A county within a specific network or service area which does not have an adequate number of providers
100
What do we search in documentation to find the General Limitations or Exclusions?
Search "War"
200
Are Chiropractic visits covered on Utah Individual plans?
200
When should we update a PCP?
At the member's request
200
How often can a preventive colonoscopy be billed?
Once every 5 years for anyone aged 45-75
200
What are the NWPR Prefixes for Idaho?
N001, N014, N015
200
What does it mean when a provider states they want "All levels of care" for Mental Health benefits?
A full breakdown of Mental Health benefits > i.e Office Visits, Inpatient, and Outpatient
300
Are there limits for Chiropractic visits? If so, where can we find them?
Yes! Check the MPS
300
What department is responsible for finding In Network providers for a member?
The Advocates
300
What services does a Global Fee include?
Prenatal, urinalysis, labor/delivery, and one post partum visit
300
Who handles provider calls for claims that have process with United Healthcare?
UHC Shared Services
300
What site/program do we use to verify an injectable code?
The Rx / Injectable lookup tool
400
Is Speech Therapy covered with a developmental delay related diagnosis for Grandmothered plans?
400
What information is needed to verify panel status?
Name and address. NPI can be used as a last resort option
400
What type of services may be considered as preventive? List at least 5
Physical/Wellness Exam, Colonoscopy, Breast Pumps, Cologuard, IUD/Birth Control, Sterilization, Lung Cancer Screenings, Gynecological Exam, Mammograms, MNT
400
How do we identify the networks for Idaho?
By Regions: IDR1, IDR2, and IDR3
400
Is J3247 a covered benefit?
Nope!
500
Do rehab therapy visits with a primary MH/CD diagnosis (including Autism Spectrum Disorder) apply to the visit limit?
No, they do not apply to the visit limit
500
When do we check panel status?
On ALL pre-service calls
500
What is the frequency of a preventive eye exam?
Once every 365 days with a 30 day grace period
500
How can we find out if a member can be seen outside of our service area/state they reside?
Network Reference Guide>Product ID (Plan type)>Benefits Applied (INN or OON)
500
What is the difference between a limitation and an exclusion?
Limitations may possibly be covered but an exclusion is never covered by SH
