Claims
What is an EX code?
A 3 digit alphanumeric code that provides information about the status and resolution of the claim.
What is the Contract number affiliated with many Florida HMO plans?
H1036
CSNP- Chronic Special Needs Plans
DSNP- Duals Special Needs Plans
ISNP- Institutionalized Special Needs Plans
Which Plan includes coverage for Behavioral Health Services?
Hide
What screen does the CAS CLAIM Prefill link take you to on the CRM Claims Detail page?
MHI
If you are sending a claim back for rework to CRU, how many claims can be included on each case?
One per case! Unless there is 25 or more!
How are PODs assigned?
PODs are assigned based on the member's current PCP.
What is the maximum amount of time for the Grace Period with DSNP plans?
6 months
BONUS: TN plans are 90 Days.
Which system is the preferred source for identifying the Care Coach?
CGX 2.0
What CAS screen shows you all the claims under a specific Month and Year?
MDI
With inpatient admissions (SNF, Hospital, ETC) there is a benefit period. What is that benefit period?
Member cannot be readmitted within 60 days of the last discharge for their inpatient stay. After 60 consecutive days have passed a new period starts.
What tool do we use to identify PODs (in mentor)?
What screen in CI verifies we did receive the VCC form?
CNSP Screen
If a member loses their Medicaid coverage, what happens to their Hide/Fide plan coverage?
Goes into a 6-month deeming period.
What link in CRM (under the umbrella page) will take you to the CRI screen in CAS?
CAS COB Prefill link
We cannot reimburse for Services preformed by an In Network Provider, they can work with the provider for reimbursement.
True or False: Members are required to see that assigned POD no matter what circumstances.
False, they can request for a change in certain circumstances
Where can we check on the member's Medicaid eligibility?
MEVH screen in CI, Case History in CRM, and Debut.
Members enrolled into a Florida LTC plan refer to whom for questions in regard to their plan?
Care Coordinator
What Modifier from the MHI Screen Modifiers mentor shows you check information on the claim?
K Modifier
For Member Submitted Claims...how can we see what documents were submitted in for the claims in CRM?
What number in CRM do we use to search for the specific POD the member is assigned to?
Grouper number.
What levels of Medicaid are Cost Share Protected?
QMB, QMB+, FBDE, SLMB+
What section under Member Central in CGX can we check for the care coach if its not listed in crm?
Additional Details tab, if not there CP CM Cases.
What is the process of checking on a Financial Recovery claim from the MHI screen?
1. Shift + F2
2. R in the S field on the recoupment amount.
3. F9 to look at the summary page.