It's just Benefits, baby.
The website that can be used to locate benefits for members.
What is B360?
When searching to see if a member is eligible, I will use this resource.
What is Facets?
When starting a call, I must HIPAA verify by asking for this information about the member.
What is the member's name and date of birth?
This person is the trainer, teaching you all the good stuff.
Who is LyQuan Graves?
This website houses our medical and behavioral health authorizations.
What is ICUE?
ICD 10 DX code: S12.01xa
You would go here to find a description of this code.
What is Knowledge Library?
After checking that a member is active, I can use this tab to see if a member has any other insurance on file.
What is COB?
"Afternoon. This is Polly, your provider service advocate. Can I have your first name?"
"Good afternoon! This is Polly, I'll be your provider service advocate today. Who do I have the pleasure of speaking with?"
Even without hearing them, you can tell that one Polly had more pep in her step. There's alot to be said about the way we say things. This guiding principle is called _____.
What is Tone and Inflection?
NORTH CAROLINA!!! These ladies are the supervisors handling those Tarheels (Tarheelians? Tarheelites?)
Who is Ashley (Prudent), Lauren (Maygar) and Briana (Williams)?
When searching for authorization requirements, I will use these resources.
What is PNL (for DSNP) and EPAL/SSG (for Medicaid)?
The location where you would check on all recent 411's.
What is A.P.R.I.L. Tool or 411 Repository?
A provider calls in extremely upset after discovering that a member's eligibility has AFTER they have been scheduled for a major surgery. Our information confirms this and we do not have any other insurance on file for the member. The provider then has a venting session about the member not informing them. Rather than try to rush them off the phone, we listen to their frustration and consider their difficult position.
This guiding principle is called ____.
What is Empathy and Compassion?
HIPAA was designed and implemented to protect _____.
Who is the member?
One caller is very upbeat and personable, cracking jokes and discussing sports with you.
The next caller is very dry and quiet. She tells you the needed information in a clipped tone and asks brief, directly-to-the-point questions.
We'll meet each of these callers on their level in order to make the interaction both useful and pleasant. This guiding principle is called _____.
What is Adaptability?
When a member is admitted to a hospital, this type of authorization is created.
What is Inpatient of ER Admit?
You receive a claims call but you haven't been trained on claims yet! Never fear. This link in A.P.R.I.L. can guide you through the call.
What is the C & S Claim Research Job Aid link?
This community and state plan will always be this if there is another active insurance on file.
What is the Payer of last resort?
Provider calls in and instantly tells you he has been transferred back and forth for over 10 minutes and everyone tells him that they can't help him.
You respond with "I'm very sorry to hear that! I'll make sure either I get this handled for you or I get it into the correct hands."
This guiding principle is called _____.
What is Issue Ownership?
This group rolls deep. These supervisors collectively handle Tennessee and Mississippi. It takes a village indeed.
Who is Mary (Breland), Kristin (Nunley), Kenneth (Johnson), Melissa (Vaughn) and Kim (Rasnick)?
DME is considered this type of case.
What is outpatient?
A provider calls in wanting to know about coverage for a breast pump. That would be found in this B360 tab.
What is benefit for DME coverage?
G. Rath has effective dates as listed below:
Eligible: 1/1/20 - 2/1/21
Ineligible: 2/2/21 - 4/1/21
Eligible: 4/2/21-1/5/22
Provider is asking about day of service 3/21/21. The member would have been ____.
What is ineligible?
When a provider does not have the member's name and date of birth, I can use this resource to locate other ways to HIPAA verify.
What is the Call Handling Onesource from Knowledge Central?
This person is the business manager, our head honcho so to speak.
Who is Nicole (Madlyne) Tucker?
When creating an authorization, I always use this resource to fill in the correct Service Setting, Place of Service, Service Detail, Service Description and Subcategory. It also helps me in knowing who my Requesting Provider and Servicing Provider is and how to enter my codes.
What is the Auth Entry Grid?