Benefits
What tab in HPDB would you find the plan's overall deductible and out of pocket max?
Schedule Of Benefits
What is the most up to date system to use when checking claim status?
CPS
Who handles take home drugs for the majority of NYCE?
Drug Vendor / Prime Pharma
Where do you search directly by document handle number?
Document Handle!
What tab in HPDB would you find benefits for gym reimbursement?
Covered/Excluded - Fitness Programs / Check attachments tab
How do you find the Home CFR for a group?
BWAA screen / Option 41 w. MID
What is T1/T2 ded for NYCE?
$0
How do you search Onbase Docs by Claim number?
*All OnBase Docs by Claim Number
What tab would you find non ambulatory travel to or from Dr appointments?
Covered/Excluded -> Medivans
Who should you tickle claim adjustment to INITIALLY when updating OI/AD for a denied claim.
Yourself - SST after 2 days if not auto adj
What form do you use if the caller is disputing network status within UHC choice plus?
NetOps Dispute -> Particpation Review
What is the difference between type of disability 01 vs 09 in the condition screen?
01 = Medical 09 = Routine
How do you determine if a claim processed INN vs OON in CPS?
Provider button / Check the OPI
What is the reimbursement rate for OON claims?
Medicare allowed amount
How do you find appeal status?
Reporting -> Shared w. me -> Appeal cases by Case/Member/CCN
What tab of HPDB would I find details about Transition of Care?
Misc -> General
How do I find updated check details for an adjusted claim?
Page forward to the most recent adjustment date before clicking Get Check Detail
Can a NYCE member be medicare prime?
No
What are 3 necessary pieces of information needed to process a member's claim?
CPT / DX / Address / Proof of payment /