Eligibility
Name the financial class/Payor that will have a Home Plan and a Host Plan.
What is BCBS?
If a Payor states a Retro-Authorization can be obtained. What should your next step be?
Attempt to verify how to initiate a Retro-Auth( i.e. through portal, form, fax, phone etc.)
List at least 3 "Common Records Requested" from a Payor
Clinical Notes
Progress Notes
Pathology Report
Physicians Notes
History & Physicals
SOMN (Statement of Medical Necessity)
Lab Reports
Order Requisitions
True or False
Both PO and CG have Waiver of Liability (WOL) appeal requirements and will use different WOL letters.
True
PO and CG have Waiver of Liability (WOL) that must be submitted with Medicare Advantage Appeals
What is the name of the network Exact Sciences/Abbott then uses to determine the Ordering Providers primary address location for locating the BCBS Host Plan.
What is VEEVA?
Part of Eligibility Basics is Accurately checking Eligibility what does this Ensure?
Claim Denial Prevention
Un-Necessary Patient Statements
Timely Reimbursement
Maximum Revenue Recovery
True or False
PO and CG have different instructions on processing Prior Auth Denials?
True
What is the abbreviation for the ROI Smart Phrase?
What is ".RCTROI"
When preparing an appeal, where can you locate an Appeal Form for a specific Payor.
What is the Matrix Suppression List located in the workbook.
This Tip Sheet is a great resource to to ensure you are creating a concise yet thorough account note.
The Guarantor Note: Creating a Thorough Note with SmartPhrases Tip Sheet
NEEDS to build:
Payor Name
Subscriber ID
Subscriber Demographics
Claims Mailing Address
True or False
Prior Auths can be located in the following places:
Referral Module
Claim Image
Registration Documents
True
What is the name of the Medical Records Request Form?
GHI ONCOTYPE DX MEDICAL RECORDS REQUEST
Form
Name at least 3 Required noting elements for noting an Account.
Payor Information
Actions Taken on Account
Phone Call Made
Coverage Updates
Matrix/WOL Info
What are the 3 Resources that can be used when working a Prior Auth?
What are
Prior Auth Tip Sheet- PO/CG P&P’s will direct you when to refer to the tip sheet
Claims Actions Tip Sheet PO/CG
How to Send Letters in Epic
Name the steps for Terming Old Coverages in Epic?
Term incorrect coverages
Term coverage with incorrect financial class
Erroneous/Old Coverages
When would you use the Infinix Portal?
Use the Infinix Portal to view additional details when a prior authorization was obtained or an attempt was made to obtain one.
The most recent PO Account has correspondence indicating the documents requested were not received in time and the claim will not be processed for payment.
What should we do next?
We will still send records for PO accounts.
These specific "work instructions" are used to help guide PFS Associates on department operates and ensure consistency, compliance and efficiency in daily account activities.
What are Policy & Procedure Work Instructions
Name at least 3 of the Eligibility resources?
Eligibility & RTE Tip Sheet
Eligibility – RTE Response Types Quick Guide Tip Sheet
Approved Payor Portal List
Known System Issue
Payor Tips Section
Payor Phone Log
Financial Class Tips Section
Name the two portals that are utilized to check Medicare Eligibility?
Connex Portal – Cologuard (ESL)
Noridian Portal – Precision Oncology (GHI)
What does it mean when Box 23 shows an Exact Sciences CLIA number?
What is the claim was submitted without a prior auth.
What documents should be removed from a Records Request Packet.
The post correction process includes which steps steps:
Verifying Eligibility
Removing Payor Contractual Allowances
Updating Registration
Demanding a Claim
Creating CASH Post Correct CRM
When Contacting the Payor name the Tip sheet that should be referenced?
What is the General Information about ESL Products Tip Sheet?