Legislation
An online site you go to find Regulatory Requirements and Mandates.
What is KL Knowledge Library?
Decision that may be made by a CAC when the benefit plan indicates coverage for services are pay codes.
What is an Administrative Approval?
Two sites that can be used to do a quick check of Benefit Plan Exclusions.
What are IBAAG and PASS?
This is the first piece of information the Reviewer should look for prior to starting to screen the case.
What are the Effective Dates of Eligibility?
The phrase we say to ourselves to remind us to start a case in the correct Platform prior to beginning our Benefit Review in HSR.
What is "Big Notification, Little Notification"?
The Funding Arrangement that bears the monetary risk and provides full financial protection for our customers.
What is a Fully Insured Funding Arrangement?
The first site one goes to when reviewing the case's Service Codes.
What is EPAL (aka PNL)?
The site/tool used to find the complete Benefit Plan for Large to Medium sized accounts.
What is Doc360?
Case Identifier used most often to search for a specific case or to communicate to a teammate about a specific case.
What is the SRN Service Reference Number?
The number we use to search for family members on the same policy?
What is the member's ID number?
The Funding Arrangement which is known for providing coverage for teachers, state and city government workers.
What is NEASO?
The site used to see if the requested code has Claim Processing Instructions (CPI).
What is (KL) Knowledge Library?
The site/tool used to find the complete Benefit Plan for Small Groups.
What is PRIME?
These must be entered correctly when the case is built to ensure Medical Claims pays everyone correctly.
What are the Provider Roles in the Provider Tab?
Referrals made by the PCP can be found at the bottom of this Tab in HSR.
What is Tab 13 History Tab?
The document in KL where you find specific State Requirements including TAT?
What is the URUM Grid?
Document which serves as the 3rd stop for Medical Code Review. Before we Administratively Approve a service code we must stop here.
What is the Paycode Exception JA?
Where emails are uploaded that refer to clarification of Benefit Plan Language.
What is CBCG?
Found on the left-hand navigation panel, this piece of information can help the Reviewer determine where to look first for the Benefit Plan.
What is the Policy number?
The Tab in HSR where you can send Approval faxes or Requests for Clinical.
What is Tab 11 - Review Request?
The tool used to determine the SOJ when the SOI and SOR are different.
What is the Applicability UR Decision Tree?
A list in KL which a Reviewer must look at prior to Determining a case with an ASO Funding Arrangement when PNL indicates the requested code is a General Paycode.
What is the ASO General Excluded Accounts List?
This is the UHC Generic Benefit Plan for SPDs.
What is the E&I Benefit Template?
This Job Aid is where a Reviewer can find whether or not a Member's Plan has only INN Benefits or both INN and OON Benefits.
What is the Summary Plan Description JA?
The Tab in HSR where you can check to see if all of your compliance requirements have been completed.
What is Tab 5 - Decisions Tab.