Benefits
This type of visit limitation allows for additional visits based on a medical necessity review.
What is a soft cap?
This type of case can be retro-authorized up to 93 days and does not require CPT codes.
Provider networks to not apply to this type of policy.
What are Indemnity plans?
When providers ask for this, they wish to know the received date, processed date, member responsibility, payment details, and ICN.
What is the claims status?
This department handles concerns regarding network discrepancies, updates, and general maintenance.
Who is Credentialing?
This type of DME can only be rented, not purchased unless their benefits state otherwise.
What is a continuous positive airway pressure or CPAP device?
We should check this indicator to verify whether authorization is required for INN physical therapy.
What is the Optum Health indicator?
This type of benefit period can start at any month of the year.
What is a plan or service-year benefit period?
We access this tool to verify the rejection reason of a claim.
What is ECHO?
We access this SOP/Tool to determine where to refer misdirected contacts.
What is the Redirect Reference Tool?
We typically check here first to verify whether odd things such as jacuzzis, hypnotism, and tattoo removal are covered.
What are the exclusions?
This special type of case is requested for OON providers to render services while the member still benefits from their INN coverage either for clinical or geographical reasons.
What is a gap exception?
This type of consumer spending account is entirely member-driven.
What is a health savings account or HSA?
This document number is also called a document control number or DCN by our providers.
What is a FLN?
We access this database on a daily basis for breaking UHC/UHG updates, news, and memos.
What is the 411 Repository?
For an EnI plan with a product year of 2014, we would check this benefit to obtain the coverage details for a medical drug.
What is the Pharmaceutical Products benefit?
This entity handles the case creation for radiology, cardiology, and gastroenterology authorizations.
Who is Evicore?
When a dependent has two internal commercial policies, one through each parent, we consider this rule to determine which is primary.
What is the Birthday Rule?
Claims that are placed on hold to request additional information are typically in this status.
What is Closed status?
We access this SOP to be certain of specific buy-and-bill requirements.
What is the PPR Pharmacy Roles and Responsibilities SOP?
This benefit is a hybrid which includes the following individual benefits Physician's Office Visit, Preventive, Professional Fees, Hospital Inpatient Stay, Minor Lab/X-ray/Diagnostic, and Outpatient Therapeutic Treatments.
What is the global maternity benefit?
We should send an escalation email instead of accelerating the case through SPIRE for this type of authorization.
What are Orthonet cases?
This 5-digit number is used to submit claims electronically and may be requested with the claims mailing address.
What is the e-payer ID?
This type of appeal is still handled by provider services even though we do not handle the benefits or authorizations for the vendor.
What are pharmacy/Rx appeals?
This type of provider credential is sometimes required in their contract to be considered INN with certain policies.
What is a consumer specific or group specific IPA?