Codes
EX Code Guide CCC Provider!
What system is always used FIRST to start a claim call?
CRM!
CRM 1st, CI 2nd!
What is the copay for DME?
$0 copay as long as member goes INN
Why do we have to follow HIPAA?
To protect patients and their confidentiality!
We always verify a good callback number!
TRUE!
What description shows for EX Code 007?
Request for Medicare EOB
You are investigating a claim and see it has been pended. Do you communicate this to the provider?
NO! Never tell the provider a claim has been pended! Inform the claim is still processing!
How many visits per year is approved for Home Health?
36 nursing and/or home health visits per calander year! Make sure they are going INN as well!
What is an NPI?
National Provider Identifier specific to a provider!
We ALWAYS aux meals for lunch in genesys!
FALSE! LOG OFF for lunch in genesys!
What mentor document is needed for EX Code 016?
Turnaround Time Expectations CCC Provider!
What mentor document is needed to check claim status?
Claim Status Overview CCC Provider!
What are the base services covered for Opioid Treatment?
Covered as medically necessary, includes 6 phase programs!
If a member has NOT been authenticated, can we release the effective date of the plan?
NO!
We always cold transfer no matter what the call volume is!
FALSE! Depending on the call volume, your supervisor will put in your team chat if its warm or cold transfers!
What do you advise the provider when seeing an EX Code 014?
Advise the caller that services are not covered when provided at no charge to the member. If needed, advise the caller to submit a corrected claim. DO NOT send to CRU as CRU cannot adjust the claim.
Why do we use the RFI screen in CI?
RFI screen shows us referrals submitted from a member's PCP.
We would first check CRM Auth/Ref tab. Remember, CRM 1st, CI 2nd!
What base services are excluded for telehealth visits?
Physical, Occupational, Speech, and/or Hearing services!
If a provider has NOT been authenticated, can we release contract information?
NO!
We can clock out 10mins early because we clocked in 10mins early!
FALSE! If my schedule was 9-5:30, I would not LOG OFF until 5:30
You are investigating a claim, you see 2 EX Codes for 2 different services. What is the description for each?
016 & 017
016- Pend for pre-existing investigation
017- Clarification of diagnosis code requested
What is the control line to reach the MRI screen?
MRI,Member ID
How many eyeglasses per year can children under 21 receive?
2 eyeglasses per year!
Besides verifying the tax id/npi, what else is needed when speaking to a provider?
Callers name, callback number, and facilities name!
Medicaid members can see any provider they want!
FALSE! Only INN providers UNLESS there is an approved waiver on file allowing them to go OON!