Coordination of Benefits
Enrollees have both Medicare & Medicaid. Certain individuals who qualify for full Medicaid benefits are called Full Benefit Dual Eligible.
What is Dual Eligible Enrollees?
Conducts a second level review for medical necessity.
Who is a Medical Director?
Must be verified before an authorization is built or services are reviewed for medical necessity.
What is Eligibility?
Is a request for prior authorization from the health plan for services to be rendered in the future.
What is Pre-Service?
File Net/Content Navigator, FAX, Phone or Provider Web Portal.
What is Auth Requests received?
Plan would cover all LTC and MMA services.
What is Comprehensive Plan?
Responsible for the daily coordination of care management and similar specialty programs and apply approved UM criteria to new or continued service requests.
Who is a Prior Auth Nurse?
Eligibility for these members must also be verified in OMNI.
What is Ambetter (Market Place)?
Members and Providers must be informed of an adverse determination both verbally and in writing within a specified timeline per lines of business.
What is Denial Notification?
Pain Management, DME/O&P, Home Health, Genetic Testing, Drug Testing, Outpt Surgery, Elective Inpt Surgery and Inpt Services.
What is Prior Auth Service Types?
The process of determining which of two or more insurance policies have the primary financial liability of processing claims payment and the extent to which the other policies will contribute.
What is Coordination of Benefits (COB)?
Performs concurrent reviews on hospitalized members to ensure the inpatient stay is in accordance with evidence-based guidelines and coordinates discharge planning.
Who is a Concurrent Review Nurse?
Emplstat Code: MMAC-SSIAB
What is member has Medicare Primary?
TAT
What is Turn Around Time?
This is used to pay Par and Non-Par physicians for surgical procedures that require an authorization and needs to be performed in an inpatient hospital setting.
What is Inpatient Services?
When a member is insured with other coverage upon admission to a facility but become eligible with Sunshine Health during that admission.
What is Other Insurance Primary?
Collect demographic data necessary for preauthorization and approve specific services for which there are explicit criteria.
Who is a Referral Specialist (non clinical staff)?
MMAC-LTC Eligible Medicaid Only with age qualifier
What is MMA & LTC member?
Requested Service - Decision TAT: 48 hours
What is Urgent (NCQA) or Expedited (AHCA)?
Admission for medical reason or not specified by specific authorization template.
What is Medical Service type?
This service includes Skilled Nursing services, DME, Therapies, Hospice and Transportation.
What is Mixed Services?
Arranges and staffs Home Health and DME services. Communicates with providers and collaborates with participating pharmacies and other outside entities to provide timely services.
Who is a Program Coordinator (non clinical staff)?
Emplstat Code: WX; WY or WZ
What is Child Welfare?
Type of Service that evaluates ongoing medical necessity of care being provided in an inpatient facility.
What is Concurrent?
Newborns detained for social reasons
What is Boarder Baby