ACTION ITEM
When you receive action items that are inquiry letters from Medicaid, Medicare, or Health insurance, and it is about claim status, specifics on the claim, amount paid, etc..What action is needed?
Tag as "INQUIRY ONLY" and then you can delete the action item
What is our goal for % DID to VM?
What is the goal for total time to return VM?
40% & 24 hours
What flower thrives in Summer because it loves the sun?
Sunflower
What 2 diaries are a top priority
Initial contacts/customer expectations
MMRS
What are progressive 5 core values?
Integrity, Golden rule, Objectives, Excellence, and Profit!
45 DAY APPEAL
Forward to --"NY45APL"
Re-index & Medical "APPEAL"
What are 3 forms of contact other then calling?
Texting, CC360, email
What is the most popular sold item??
Swimsuits.
When you see "system issued diary"
For example--THE FOLLOWING INFORMATION IS MISSING OR INVALID FOR MDP BILL ########:
PROVIDER TIN
CORRECT THE INVALID TIN IN MDP, REVERSE DECISION TO COMMIT IN MDP AND
RECOMMIT BILL
Where do we forward these?
EFFNY
What are the unit goals for actions items and bills in MCR RVW? WHY?
5 DAYS, 10 DAYS
BE TIMELY MEET REG REQUIREMENTS!
Req for NF10, IME/EUO notices, Copies of IME/Peer medical records, Proof of mailing, Verification and cashed drafts, Dec page
ATTY Document Demand Letter
What should we explain to the customer at our IME Apt reviews?
Appointment details including possible denial of benefits for failure to attend and cooperate.
Where in NY holds a hot dog contest on Independence day?
Coney Island Brooklyn NYC
Who would you need to send a diary to on the claim when we issue an IMEW?
Wage rep! FYI denying wages--Team work!
Per the NYS Reg how many days do we have to address the nf2?
Within 10 business days after receipt of the completed application, the insurer shall forward those prescribed verification forms it will require prior to payment.
What do you do when you recieve a UM/UIM Notice?
1. Immediately Alert the UM or BI Rep in ALL ways possible!
2. Forward the A/I to the UM/BI Rep
3. AND Diary the UM/BI Rep
4. AND send a Team Message to the UM/BI Rep.
5. If no active or if no UM/BI Rep, Send a Diary to "YONKERS" and enter a claim note to summarize the document and include scan date and # of pages. Diary Subject lines: "UM ARB (Insert EIP Name)-C Note". NOTE: Do Not Forward ANY A/I's to "YONKERS"
6. Re-label as "Medical / Arbitration"
7. Tag as "UM Arbitration"
What are the steps in completing an IME Apt verification?
1. 4. check mdp for new significant changes, injs? sx? discharged?
2. contact all providers appliable for that specialty, verify most recent dos, freq and any new changes in plan.
3. contact the customer confirm they are aware of the appointment and the importance of attending, failure to attend can result in denial of benefits, and confirm that treatment is ongoing
4. if atty repped contact the attorney to confirm apt details/in addition to any upcoming surgery, injections of settlements we are unaware of.
5. Document decision with rationale, if we have the information needed.
6. If we don't have the information needed to make a decision, complete a follow up apt verification to confirm.
How much water is in a watermelon?
A: 99%
B: 92%
C: 80%
D: 85%
What do you do with a bill that was denied in error and needs to be paid? what are the steps?
1. reconsider the bill
2. remove overrides
3. check MCR approved
4. note in the description box "O/T DENIAL OK TO PAY -MM 9/22
5. Manually save in the reconsideration queue
15 days
When you receive an EOB, NF10, or Verification Request and/or returned checks on a non-PIT bill. What action should be taken?
1. Tag the document with the bill #
2. Forward the action item to PROVMAIL
What is one key principle to providing excellent customer experience?
Responding with urgency!
Showing empathy!
Setting clear expectations on coverage!
Check in and update your customer along the way of the claims process!
What is the longest beach in America?
Long Beach, WA. 28 miles long!
When you reject an active invoice for payment what are the next steps?
Diary "EFFNY"
Claims pro note with bt# that was rejected, and what action is needed
What steps do we take to address a notice issue?
1. Obtain R/S from EIP why were injuries not reported within 30 days from accident?
2. Contact the cc were they aware?
3. Contact the agent were they aware?
4. Listen to FNOL stmt is this our error? were injuries mentioned?
5. We act fast on this as we have 30 days from report to make a decision!