Systems
How can you tell if a provider is in network via PAAG
MCD: Humana Healthy Horizons (HHH) Virginia (VA)
INTG: Humana Dual Fully INTG
A provider calls in and they are requesting the status of a check and he amount of the check. What authentication steps if any would be needed?
HIPAA Overview CCC Provider:
Note: If given 2 other payments, those payments must be validated/located in the Check Status Tool or ARI.
Is PA required for CPT: 97553, 41512, 32850
97533:Yes
41513:No
32850: Yes
When using CAS what is the reason for suffixes on the claim screens?
Suffixes display the total number of policies the members have.
Example:
1- Blank
2- 1
3- 2
4- 3
5- 4
In Tarzan what was the animal that killed Tarzan's family?
A Leopard
Use Training CRM what is the quick link for accessing the members Primary Care Physician information?
PCP
A provider calls in requesting a EOR be sent to them due to them not receiving the first one. it has been 5 days since the claim has processed. What steps do you take?
You will inform them to allow more time for the delivery of the EOR as claim finalized on xx/xx/xx and it can take up to 14 days to receive it.
There are times when you may need to put a caller on hold. Which of the following must be done when placing a caller on hold?
Ask for permission, wait for response, provide estimated hold time, and check back with caller when hold time is longer than communicated (Hold no more than 2-minute increments)
Why is it important to check the PDI screen before requesting/ Sending a Stop Payment Case to PPI.
To verify the providers address is correct and new check is not sent to the wrong address.
How many sister's does Ariel have in The Little Mermaid?
6 sisters
Attina, Alana, Adella, Aquata, Arista, and Adrina
A provider calls in stating they received a check, but no Explanation of Remittance. They want to know the members and claims the check was for. Where would you locate this information?
Associate Remittance Inquire (ARI)
A provider calls in about 2 members. First member is MCD policy and they ask about benefits, auth requirements and credentialling status. The second member is Dual INTG and they ask about Auth Status, Claim status, credentialling status and eligibility. How many cases in total do you think needs to be created?
Double Points!!
MCD Policy: 3 Cases
INTG policy:5 Cases
Provider Account: 1 Case (Credentialling status case)
Total Cases: 9 cases in total
A provider calls about multiple members during one call, what information if any needs to be updated in the interaction log?
Both the Member and Provider With/ About
In CRM what are the main two Quick Links you have to enter two specific CAS screens?
Hint: One is on Plan Member page one is in Claim Summary page.
Double Points!!
CAS COB Prefill: Takes you to the CRI Screen;
CAS Claim Prefill: Takes you to the MHI Screen;
What is the famous movie that involves 2 people sharing a door?
Titanic
In CRM when is the only time you do not select CLOSE CASE on the Case Edit page?
When you're transferring a case to a different dept
When a Supervisor/ TL tells you to keep it open (Save) status.
When a provider is challenging the recoupment about a duplicate Explanation of Remittance and remit/deduct applies, the call should be transferred to _______________.
Provider Payment Integrity (PPI)
What is the explanation of the following code: 0X(
Description: Other Insurance Information Indicated On Claim.
What is the indicator on the MHI Screen that the claim has been in Financial Recovery?
FR: Y/N
What is the movie where a robot goes to space to save a plant?
Wall-E
What system do we use to look up if a member has a Care Manager/ Care Coordinator?
Guiding Care
A provider is calling in to find out if they need an authorization for inpatient heart bypass surgery. The provider is part of AllCare IPA and the grouper number is 08055186. What guidance do you give this provider?
Double Points!!
Contact the Delegate for inpatient authorization
What Aux do you put your phone on when going to lunch while on calls in production?
There is not an Aux for Lunch you would log out of both of your CRM and your Genesys and log back in when back from Lunch.
When you are using CAS and the Red Stick Figure appears what key on your Keyboard do you need to press to remove it?
CTRL
What's the address to the Dentist office in Finding Nemo?
P Sherman, 42 Wallaby Way, Sydney