This type of authorization will cover all of the following services:
the therapy, administration, medication and all other codes
What is Chemotherapy authorization
100
What do you do if a provider submits with global codes 59510, 59400 or 59610?
What is deny these codes for R51/X51-"Service Not Covered" and comment in the Notes Page "Global codes not covered."
100
The authorized _______ does not have to match the billed procedure code when billing for observation services.
What is procedure code
100
1) There are 6 types of therapy services include ?
1.What is physical
2.occupational
3.speech
4.chemotherapy
5.chiropractic
6.radiation therapies
100
This type of testing is a covered benefit for all newborns when services are provided within 30 days of delivery
What is bilirubin testing
200
This term "Capitated to Another Provider" defines what Ultra Blue Message?
What is X64
200
What should the Doctor do when a member is identified as being pregnant?
What is the OB/GYN is required to obtain a Mom's GEMS (Get Early Maternity Services) authorization.
200
The line and units should be split out to pay for the 23 allowable hours and the other hours should deny R46 - "Over Max Procedure/Benefit Limit"
What is the observation service spans more than 23 hours
200
What will happen If the provider is billing for a subsequent office visit?
What is the system will automatically generate the line denial PS0 - "Not a Covered Service."
200
: Claims for outpatient services performed at this facility or the affiliated specialist should be paid whether or not the PCP indicates the correct provider name/ID on the referral
What is Cooper
300
Blood storage is considered a laboratory service and is covered by the rules for labs
What is radiation therapy services
300
What type of services do the GEMS authorization cover ?
What is all OB services including the delivery, and post-partum care
300
An observation authorization covers any service billed with POS ___ with the exception of surgical procedure codes, regardless of affiliation with the authorized provider
What is POS 22
300
What are the 3 Physical Therapy Codes?
What is 97001, 97002,97110
300
This procedure can be completed by a provider or facility using only the referral process (Hint: type of study)
What is Sleep Studies
400
The following ________ codes (96401/96402) are payable (with an allowable authorization) whether or not J Codes are also billed or regardless of number of units billed.
What is Administration codes
400
What will Facets do If the provider billing is not part of the authorized provider's group,?
What is flag the services for an authorization.
400
IF:the authorized facility ID does not match the billed facility ID
AND: the authorized date of service matches the billed date of service
What is (What should you do- 2 things)
1.pend the claim SMR1 - "Medical Claim Review - Authorization"
2.submit a SF to the Claim Med Rvs Phila - Catch All queue
400
_______ providers do not require an authorization/referral for the initial evaluation or for re-evaluations.
What is Par
400
This specialist does not need to be affiliated with the facility when billing for services performed in an outpatient (POS 22) setting. If there is an auth/referral for the facility to be paid, the specialist should also be paid
What is radiologist
500
The following chemotherapy procedure codes are not covered during an inpatient admission and should be denied :
96410 - Chemotherapy administration
96412 - Chemotherapy administration
96414 - Administration of chemotherapy
What is R51/X51
500
What do you do if a PAR OB/GYN/Midwife does not generate payment and requires an auth for the service ?
What is forward the issue to your Supervisor for review
500
IF:a physician bills for any service other than observation or surgery with POS 22
AND: an observation authorization exists
What is (what should you do)
Attach the 9999 unit line of the observation authorization and pay the service
500
DOUBLE JEOPARDYYYYYYYY
Type of providers that may provide therapy services are?
What is
Facilities
Therapists
PCPs
Chiropractors
Podiatrists