Medical Review
What is the process of assessing claims for medical necessity and pre-existing conditions
What is Medical Review
CALLERS MAY SPEAK WITH MEDICAL REVIEW DIRECTLY, AND CSD REPS MAY EMAIL THEM DIRECTLY
What is this is FALSE>
When a faxed request is received, the request will be imaged and viewable as an inquiry_____hrs
What is 48 hours.
Always verify the service is not __________ per contract benefits
What is EXCLUDED.
Where can medical records request be made in cis?
(A) cis subscriber member
(b) cis history
(C) cis Med Recs
What is CIS MED RECORDS
How many levels are in the post service review process?
What are three levels.
Each claim is systematically reviewed (Level I review) to determine if it can pass through the automated eligibility and coverage checks
What is this is TRUE.
Please see your _________ if a situation arises requiring contact with Medical Review. This includes priority requests.
What is your SUPERVISOR.
If excluded no ______________ is done.
What is PREDETERMINATION.
What is predetermination type inquiry?
(a) PE
(b) PT
(c) PD
What is PD.
Blue Cross and Blues Shield of Alabama Attention: Medical Review-Predeterminations P.O. Box 362025 Birmingham, AL 35236 Fax: (205) 220-9560 ANSWER: WHAT IS MEDICAL REVIEW CONTACT INFORMATION
WHAT IS MEDICAL REVIEW CONTACT INFORMATION.
If a claim cannot be processed without review, it will START and be sent via inquiry to Medical Review for a determination.
What is FALSE.
A determination of medical necessity
does NOT supersede ______________.
What is BENEFITS.
On a predetermination advise member to wait ___ days from the time all information is received.
What is 30 days.
What inquiry type is Medical Necessity?
a.) md
b.) mn
c.) mc
What is MN
PD, AL, PE, & MN ARE ALL EXAMPLES OF WHAT?
WHAT IS A TYPE INQUIRY
The services on this claim have detailed coverage guidelines per.
What is DORS.
After the predetermination review is completed by the _______, an informational inquiry (type PD) is created
What is a NURSE.
What are the first two benefit categories we verify?
What is EXPP and EXCL
If a claim cannot be processed without review it will be
a.) returned
b.) stopped
c.) completed
What is it will be STOPPED.
Inquires for ___________are not created until after a decision is made.
What is Predeterminations.
To review additional details you must enter the JIVA episode number.
What is this is TRUE.
The JIVA episode number can be taken to JIVA to review ___________ _________.
What is ADDITIONAL DETAILS.
A _________ is a review of coverage criteria before the service.
What is a PREDETERMINATION.
Level III review consist of ________ to determine if the patient meets the criteria for the medical policy and the contract benefits.
a.) doctor
b.) nurse
c.) customer service rep
What is DOCTOR.