Rep Knowledge 101
Example: 12-3456789
What is a TIN?
Dental, BH, PCP, Specialist, Ancillary
What are Provider Types?
Where Providers log in to to see their claims.
What is the Provider Portal?
Talking to a Provider about updates, changes, reminding them to use the Portal, MOC, etc.
What is a Site Visit?
A department that gives permission to perform a service.
Who is Prior Authorization?
Where Site Visits are recorded.
Care Radius Cloud
RBHA
What is the Regional Behavioral Health Authority?
Where TAT reports can be found for sharing with providers.
What is QLIK Sense?
The process in which Health Choice accepts the credentialing process an entity completes on their providers in lieu of completing our internal credentialing file process.
What is Delegated Credentialing?
When a provider disagrees with a claim reconsideration.
What is an Appeal/Dispute?
An EWE recorded call.
What is an escalated call?
A Pain Medication & Care Improvement Program for pain management providers.
Who is Axial Healthcare?
Two places where Providers can find Health Choice policies & procedures.
What is the Provider Manual & the Website?
An agreement where a provider receives for treating a specific member for a specified period of time.
What is an SCA - Single Case Agreement?
The Health Choice Team that is responsible for researching a provider when suspicious activity occurs.
Who is the SIU (Special Investigative Unit)?
When a claim does not pass through into MedMC.
What is a Rejected Claim?
EPSDT
What is Early and Periodic Screening, Diagnosis and Treatment?
MTBA
Who is Health Choice's transportation company - Medical Transportation Brokerage of Arizona?
PMMIS
What is the AHCCCS information system used regarding member enrollment & eligibility and registered providers, etc. - called Prepaid Medical Management Information System?
The communication tools/apps that the Network Team uses to stay in touch with each other.
What are Skype & Zoom?
Providers need to include W-9 and cancelled checks or bank letter.
What is when a provider requests EFT set-up?
The list a provider is put on by CMS when a provider elects to not provide Medicare-covered items and services to any Medicare beneficiaries.
What is the Medicare Preclusion List?
Having a reimbursement value of $400 and $650 for a provider.
What is the CHE - Comprehensive Health Evaluation? ($400 - completed CHE and $650 - completed CHE & EOD)
ACOM 417 report for AHCCCS.
What is Appointment Availability?
The review process that includes checking each claim line to make sure it was coded correctly, thre are no common billing errors such as duplicates, improper frequency, unbundling of services, inappropriate modifier use.
Who is Cotivity/Verscend/Verisk?
AND.... What is the code you will see listed in the claims process system?