NEW EDUCATIONS
_________ has officially transitioned to Jefferson Health Plans (JHP).
What is Health Partners Plans (HPP)
Authorization is NOT required as long as the procedure was performed in the ___
What is ER
What are example to disconnect from and automated caller and what is the script you would use?
What is The caller cannot provide an answer to the question asked, The caller continues to repeat the same information over and over again, The caller cannot verify HIPAA or PHI
“Releasing the line due to inability to [insert circumstance] from automated caller. Please call back with a live representative.”
How do I identify if a case is partially denied for Site of Care?
One of two scenarios will happen:
1. The procedure is approved and the site is denied
2. The procedure is denied and the site is approved.
The agent may look at the A script, in the journal for the partial non-certification reason, or at the partially non-certified letter sent to the member or physician.
What are some words to avoid, that may cause escalation with the caller?
Unfortunately, this is the final decision, I can not help you, this is not my department
What are the steps you would take if a caller has a Cigna Pre-Cert surgery quantity changes?
If the only change needed is to update the approved quantity/units:
❌ Do NOT withdraw the case
❌ Do NOT create a new case
✅ Send a communication to swatsme@evicore.com with specific quantity change information for validation
✅ Journal the case to reflect what the office is requesting
What is the extension for for employee restricted case?
What is 20145
T or F: An Empire case pending peer to peer can be connected to PSU line
What is False connect to live P2P
Can intake build a new case right away for the same MD and the same CPT code if it is partially denied for site of care? Is it considered an administrative non-certification?
No, a new case cannot be built right away for the same MD and same CPT code. This is considered a medical non-certification per our contract with United Healthcare.
What are some natural mid call fillers
• "Let me take a look at that."
• "I appreciate your patience."
• "Thanks for waiting while I review this."
• "I see what's going on here."
"Let's work through this together."
What should you do if you need to rebuild a case and can not withdraw the original case?
Whenever a new case is created due to an existing case, both cases must be journaled with the reason for the new case creation and the related case number.
Documentation should clearly connect the two cases.
What is the DX code if the caller does not have a primary dx code?
What is Z00.8
What is the process for admin denial cases?
What is restart the case.
If a case has been administratively denied for the site that was OON (Out of Network) Intake can start a new case for the same physician and CPT code/s, with a new in network site.
My caller is asking for a list of freestanding facilities that the patient can go to since the site was denied, what should intake advise the caller?
You may build a case up to the site selection process on page 3 using the site on the original partially denied case on page 3 and select the option none of the above on the screen shot below to get the list of alternative in network sites.
When a caller is experiencing Negative indications of frustration, how would you respond?
I can definitely hear you are discouraged. I will help get this [issue] resolved for you
I understand that the previous experience did not meet your expectations. I’m going to take over from here and see that we get [issue] resolved for you.
T or F. You change a site of finalized (A,D or Z) cases for NWHWI.
What is false.
If an OON site is requested after a case is finalized:
❌ Do not modify the site on the finalized case
❌ Do not manually enter a new OON site
✅ Follow existing ImageOne system messaging and guidance
What is true.
What is true.
Placeholder not allowed for
radiology
cardiology
gastro
Can intake simply change the site to a freestanding facility?
No, Z status is a final status and changes cannot be made to the case.
You may assure the caller that, “As long as the patient goes to an in network free standing facility, the site does not have to match for claim payment
What are some ways to close a call empathetically?
“Thank you for giving me the opportunity to help today.”
• “I appreciate your patience and understanding”
• “Please don’t hesitate to call back if you need further assistance.”
• “I’m glad we were able to work through this