Tools
The tool where all calls are documented?
SPIRE
True or False. All claims submitted to our clients (the insurance companies) will be reviewed by Optum.
FALSE
What medical records are needed if the service billed is a "complete blood count" (CBC)
physician's order and lab results
What is the operating hours for WELLMARK?
7:00am – 7:00pm CST Monday – Friday (excluding Holidays)
True or False. If we open a case in OPRS and discussed it with the caller, we need to document the interaction in the Documents tab.
False. The interaction is documented in the NOTES section.
Search engine for job aids of PIRT.
Knowledge Now / SPIRE Knowledge
True or False. We have to document all calls, even ghost calls and dropped calls.
TRUE.
In general, what service was performed if the first digit of the CPT is "0"?
Anesthesia
How many INQUIRIES/DISPUTES (reconsideration reviews) does a provider have?
UNLIMITED. Provider can submit unlimited written reconsideration or file a verbal dispute as long as it is within the 18 months timeframe from the initial process date.
What is the standard opening/greeting if we receive a WLMK call?
"Thank you for calling Optum on behalf of Wellmark."
The tool that stores cases and clinical outcomes for both professional and facility claims.
OPRS
What is the tool that we can use during our calls to help us with call flow?
Decision Tree
This describes services whether it is medical, surgical or diagnostic and is designed to communicate uniform information about medical services among physicians, coders and insurances for administrative, financial and analytical purposes.
CPTs
What is the timely filing for medical records for initial review?
60 days -- If records are not received in 60 days from the date of the first request letter, the case will close. This is a technical denial.
How many HIPAA information do we need to verify prior to discussing the claim with the caller?
At least 4
Used to provide definition or description of CPT codes, HCPC codes, ICD10 codes, modifiers and revenue codes.
Knowledge Library
How can providers submit medical records for Wellmark claims?
Mail and online.
Also known as alpha-numeric codes since it contains a single alphabetical letter followed by 4 numeric digits.
HCPCS Codes
What is the timely filing for reopening a case after a technical denial?
18 months from the original Wellmark processing date.
Yes or No. We always need to ask for the DOS and billed amount.
Yes
Where can providers upload medical records.
PI Portal
Yes or No. We can create a ticket for 2nd look if the provider for a Wellmark claim disputes an initial review denial.
Yes. Verbal dispute is allowed.
In general, what is the best answer if callers ask us what kind of records to submit?
“We need to have records pertaining to the codes that were billed on the claim.”
True or False. The provider can request for a verbal dispute.
TRUE.
In general, what is the turn around time for Optum to complete a review after medical records have been received?
15-30 business days