Product Specific
This happens with a claim if a Choice/Connect member is seen without a referral.
Tip: We're not just talking about INDI Choice/Connect members...
What is the claim processes out-of-network?
The largest network located in Oregon and SW Washington.
What is the Signature (EPO) network?
The place of service that MBR ID 112934441-00 must go for her preventive exam for the claim to process in-network. (Be specific)
Where is PMG - Sunset? (medical home)
Danielle from Dr. Laurel Westly's office/TIN 930798039 (Tualatin location) is calling to find out where to mail a claim for MBR ID 100523075-00.
Where is PO Box 3125 Portland, OR 97208?
The two benefits we quote for members going in to see a specialist.
What are the OV and x-ray/lab benefits?
These plan types apply a member cost share on preventive services.
What are grandfathered plans?
The network used for a rural area within Oregon, such as Roseburg, where the EPO network is not available.
What is the PPONOEPO network?
True or false: A choice member must be seen at their medical home for their annual gynecological exam for the claim to process in-network.
What is false? A choice member can see an OB/GYN without a referral and the claim will process in-network so long as the provider is participating.
What is Claim Pended; Following Batch Processing Entry?
BONUS Bragging Points: Can we give information out on claims in this status?
When a member needs glasses for a medical-related diagnosis it falls to this benefit.
What is the DME benefit?
The one commercial plan that is on a plan year rather than calendar year.
Hint: The group # is 100101
What is the ADEC group?
The national network that Kootenai Medical Center, in Coeur D Alene, Idago is participating with.
Use MBR ID 100426853-01
What is FCHN?
The benefit quote for an individual member getting a chickenpox vaccination at their medical home.
What is covered-in-full?
CPT Codes that start with the number 8 indicate this type of service.
What are lab/diagnostic services?
Whether or not a nerve conductive study requires a PA or not.
What is no PA required?
***QD***
True or false: An individual choice member can be seen by a specialist in Arizona and utilize the First Health network to receive in-network benefits.
What is false? No in-network benefits outside the state of Oregon, besides UC/ER.
*No MBR ID - Go in as if a prospective member is calling and is considering a group plan that utilizes the EPO network.
What is 59?
The way a claim will process if a Connect member goes to Legacy Good Samaritan Medical Center for a 3D mammogram.
What is out-of-network / not covered?
The tab within claims inquiry which indicates who "touched" the claim. (Did it go straight through Facets? Did a claims processor touch it?)
Example claim for research: CL # 190084171700
What is the status tab?
True or false: Referrals are not required for Choice or Connect members when Providence is the member's secondary insurance.
What is true?
To update an address for a member on this plan type, a CSI must be routed to MEM.MDC for changes to be made on the member's account.
What is the PERS Early Retirees plan?
Using the First Health provider directory, how many DME vendors are available within 10 miles of zip 90001.
What is 1?
What we would tell a member calling in asking what the coverage is for a sports physical.
What is not covered? (Work/School Related Services)
Tiffany from Dr. Seth Stankus' office/TIN 911939739 (J Street location) is calling to find out where to send their claim for MBR ID 100522976-00. They want to send it electronically.
What is submit to FCHN Payer ID: 91131
The place where we can refer members who have additional questions regarding PMG doctors, classes offered at Providence facilities such as birthing classes, etc. (Portland-metro area only)
What is the Providence Resource Line?