M&R Eligibility
No
All medicare plans are not considered COBRA plans
This is the benefit for Jcodes
Part B drugs
What is the turnaround time for a standard Authorization?
5-14 calendar days
What is our main tool?
SPIRE
What happens when the OOP is fully met?
We will cover 100% of the allowed amount.
How many days till the benefit period of Skilled Nursing refreshes?
60 days straight of not being admitted.
If UHC is secondary, is authorization still needed?
No
Prior authorizations from UHC will only be required when we are the primary plan.
What tool do we use in checking Benefit accumulation for M&R?
CPA
Is there a lifetime max or a benefit cap?
No
There is no lifetime max or benefit cap for all M&R plans
Is buy and bill allowed if the POS is Outpatient Facility?
Yes
buy and bill of drugs is always allowed for M&R plans, regardless of the POS.
When do we create GAP exceptions?
When the provider is OON and they want to be covered at INN rates.
Where do we check Authorization Appeals that are sent by providers?
ATS or ETS
Can we provide the members MEDICARE ID?
No
We can only verify it on our end.
What is the description code to check SNF accumulation?
8011
If the code does not require authorization in NGT, but the provider insisted to create a GAP exception. What should we do?
Advocate should still create the GAP request, regardless if authorization is required or not.
What tool do we use to get the phone numbers for different departments?
Provider redirect tool
Aside from the NPI, what specific information do we need to check the Network status of the provider?
Providers name and address
True or False
Only 1 copay will apply when the member will do both Physical Therapy and Occupational Therapy in a day?
False
The only time that 1 copay will apply for Rehab services is if it is Physical and Speech.
Who handles pre-determination creations for delegated plans?
UHC will still be the one to handle pre-determination cases, regardless if it is delegated or not.
Where do we check if the passport is activated or not?
GPS