Benefits & Eligibility
Department to reach out to when pre-d is mishandled
What are the 3 different payment methods?
Plug in action code to see if recon is available or if appeal is required
What is clinical coding database?
https://aetna.quickbase.com/nav/app/bn2py3qva/action/appoverview
How would you pull up a participating provider contract ?
What is SCM
Beginning of a call greeting
What is 'Thank you for calling Aetna, my name is () I'll be your customer advocate, how can I assist you today?
Diagnostic service which may be performed in a doctors office, freestanding sleep center, outpatient hospital, or even a patient's home, with cost-sharing that varies depending on the member's plan type.
Where to find results for CCR review?
Where you would search for a recouped payment ID when there is no payment ID listed on claim on GPS.
What is APPAYS?
We use this tool to find claim and benefit information
What is GPS
How long can an agent wait on hold?
Provider sent a W-9 with a letterhead requesting a service address change
What is a provider demographic change/update.”
What is Pass through billing
a provider bills for a service done by another provider that’s not affiliated with the billing provider (different TIN).
This administrative process lets medical professionals submit a treatment plan before care begins, allowing the insurance carrier to confirm eligibility, covered amounts, deductibles, copays, coinsurance, and plan maximums in advance.
What is predetermination
These standardized codes are used to identify medical procedures, equipment, and services for billing purposes
What are HCPC codes?
Where we check our quality and survey scores
What is Verint
This is used when looking for Plan specific Orthotics, Acupuncture, Two Rules Exist for the Same Service Group
Caller says they faxed a Federal IDR and they are owed more money
What is educating provider to email FederalNSA@Aetna.com
The time frame to request a peer to peer after an appeal denial
Provider sends in writing Name, Proposed Rates, Reason for increase request, Tin
What does it take to renegotiate providers contract?
How many breaks do we get if we work less than 6 hrs.
When quoting BH ben - what is the bread crumb policy trail to determine if a OP BH ALL OTHER ben line applies?
What is Epolicy - Tools - Favorites - Trad PCC - Benefits - Behavioral Health - BH All Other
PSPP states: We are currently experiencing a delay in processing. We apologize for any inconvenience and are working as quickly as possible to resolve your claim; GPS indicates the claim status of the claim is "internally pending" or "internal pend with errors".
what PSPP is State of Florida
https://datahub.aetna.com/pst/en/pspp/commercial1/state-of-florida.html
Provider states they are allowed a second level of appeal
What is the provider deviation tool?
https://aetna.quickbase.com/nav/app/bkt8rusmc/action/appoverview
Go to the AST/CXT screen.
Tab to Window
Type CQC and then paste the claim ID and hit F10.
Then, from the Claim Inquiry screen, Tab to Window and type H6 and hit F10
What are the standard CSR Metrics ?
SCAD, Phone Quality, FCR, and attendance