Claims
The Clean Date is ...
Date the claim was received
Using this Smartsheet we can determine if Authorization is needed
2023 Prior Auth List - MA_Cmcl_EviCore(06022023)
5 HIPPA Identifiers
What does part D Cover ?
Prescription
Upheld appeal status
The reviewing physician decided that Prominence’s original organization determination was correct.
Claim Pending Statuses
Deny
Wait pay
Wait deny
Transplant Authorizations go through ...
Tethys
Someone who you choose to act on your behalf, like a family member or other trusted person. This person may call, clear HIPAA, and ask any question's or gain information on the member. Member must complete an 'Authorization to Release Medical Information' and submit to plan.
Personal Representative:
When does a member get a Late enrollment penalty (LEP)?
When enrollees take longer than 63 to enroll in a credible prescription drug plan.
Overturned Appeal status
Overturned – The reviewing physician has decided that the original organization determination was incorrect and or sufficient information has been submitted to change the original decision
Claim Processing time
30-60 Business days
Processing times
STAT(expedited)
Standard
How long is a Verbal consent valid for
What is covered under part B?
Outpatient care, Drs Specialist , DME, ETC
Fast Appeal turn around time
Prominence will give members a decision on fast appeals within 72 hours after the appeal is received
Where can you find the claim Denial reason in Qnxt
Pay Tab
How can Providers submit a Prior authorization to the plan.
Can we talk to Brokers/ Agents on behalf of members ?
Yes
What is Part C
what is the time frames for members to submit an appeal
"You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision
How would you Identify if a claim has been adjusted.
Claim will have an A in the end of the original claim number
What state and Services go through Evicore
Nevada MA Only
• Radiology
• Cardiology
• Gastroenterology
• Physical Therapy- Effective 01/01/2023 -- After 12th Visit
• Occupational Therapy- Effective 01/01/2023
• Spine Surgery Management
• Joint Surgery Management
• Interventional Pain Management
• Durable Medical Equipment
Where do we document a personal representative after we receive the form ?
Qnxt- Under Personal Representative
What is Original medicare?
Part A + Part B
Where can we locate appeals or grievances for 2023
Smart sheets
2023 MA Appeals Log
2023 MA Grievances Log