Benefit Language
What do you use if COC/SPD is more than 5 years old.
E&I Benefit Template
BTB/IBAAG
Carrum Mandatory List is referenced in?
DOC360
What would you do for a Med Nec policy that did not purchase the Buy-Up.
Continue per standard workflow
Where do you find the DME Routing list?
Under Training and Workflow Related
What states are for P2P.
TX, RI, VT
What do you use the E&I Benefit Template for?
exclusions and definitions
After you review HSR notes and initial files in Doc360 and Appeal request for validation of exception, and the exception is not found what do you do?
return to Benefit Operations
If the provider does not agree to utilize an ASC where they has privileges, what is your next steps?
Document providers reasons and continue with standard procedure
Where can you find the PNL in the share point
In Quick Links
For CPT codes 19370 and 19371, what do they require?
submission of high-quality color photograph(s)
What is required for NON Med Nec for DME
• Durable Medical Equipment
• Cost Effective
• DME Definition
• Unproven
What do you do if exception is found.
determine if a Prior Authorization Approval is on file.
After determining the COC year, what is the next step?
if there is are age restrictions
Where do you find the Pre Service Coordinator Workbook ATS?
Training and Workflow Related
Is this a Reject? Approved codes or blank lines with no codes marked as YES under the auth line detail section
Reject
What language do you need for MED NEC Bone Anchor Hearing Aid?
• Bone Anchor Hearing Aid**
• Hearing Aid**
**Include all coverage language and any applicable exclusion language
If there is Authorization Approval is on file. What do you do?
Return to Benefit Operations to process per Prior Authorization on file.
What do you do if you are unsure if the facility being use is a preferred SOC
If unsure, and a facility is not identified in the eviCore file/Appeal, or there is conflicting information, contact the provider to identify where the service is to be rendered.
Where can you find the E&I Case Prep demo?
LPS: Systems-Demonstrations and Practice
If the on behalf of/liability field list provider, reject back to the RA for correction, except for?
Indiana
Radiation Therapy what is needed for Med Nec?
• Life Threatening (found in unproven definition)
Therapeutic Treatments
• Unproven
• Medical Necessity/Medically Appropriate
If no exception is found. What do you do?
Add a screenshot of Carrum Mandatory List,
If the facility obtained during steerage is found to not be a free-standing facility, what do you do?
Input the originally requested facility in HSR instead.
True or False?
Kiana's pic is on the share point
False
Who do you notify if you have issues and/or errors with the macro/case prep?
RRT_ClinicalAutomation_Team @ RRT_ClinicalAutomation_Team@ds.uhc.com