Medical Benefits and Eligibility
This type of doctor is allowed to bill a patient for remaining charges because they do not have a signed contract with our network.
What is an Out-of-Network (non-participating) provider?
To get this fast review instead of a routine 14-day review, a doctor must prove the standard timeline threatens the patient's life or health.
What is an expedited (or urgent) prior authorization?
This standard, 8-digit identification number is required on every electronic and paper medical claim form to identify the specific healthcare professional who performed the service.
What is the National Provider Identifier (or NPI number)?
If an adult member has two active health plans—one through their own current employer and one as a spouse's dependent—this is how we classify their own employer's plan.
What is the primary plan?
The favorite caller of Aetna's Provider Commercial Team
Who is Koras?
This is the percentage rate a member pays out-of-pocket for a covered service after their deductible has been met, splitting the remaining costs with the health plan.
What is coinsurance?
This is the clinical discussion a treating physician can request with a health plan's medical director to contest a prior authorization denial before filing a formal written appeal.
What is a peer-to-peer review?
Under CMS NCCI edits, this localized numbing method is built directly into the main surgical fee because it is a routine part of the primary operation.
What is a local anesthetic (or numbing injection) administered during surgery?
This standard rule uses a parent's birth month and day to decide which insurance plan pays first for a dependent child.
What is the Birthday Rule?
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Who is Nicholas Reed?
This is the specific insurance term used when a service or treatment is completely left out of a member's insurance policy guidelines.
What is an exclusion (or non-covered service)?
These are the clinical chart files, lab reports, and physician notes a provider must submit so the plan can evaluate if a requested service is medically necessary.
What is clinical documentation (or supporting medical records)?
This contract clause strictly prohibits an in-network network provider from billing a member after missing their claim submission deadline.
What is a hold-harmless provision?
If a member has dual active coverage under a current active employment policy and a retiree medical policy, this plan is legally designated primary.
What is the active employment plan?
OON reimbursement rates
What is the OON topic CSR's get threatened with the most, if it isn't provided?
This standard insurance provision gives parents a temporary automatic window to have services covered for an infant under a mother's active policy right after delivery.
What is the 30-day automatic newborn coverage window?
This is the clinical determination a plan issues when a requested service is denied because it does not meet established medical guidelines or criteria.
What is a lack of medical necessity denial?
This is the illegal billing practice of intentionally submitting a more expensive code to the health plan than the actual medical service that was provided.
What is upcoding?
This is the parent whose health insurance plan is automatically designated primary for a child when the parents are divorced and have no court order.
What is the custodial parent (the parent with physical custody)?
Our sassy, knowledgeable, "bullying", loving, kind, motherly TL.
Who is Leanne Knowles?
This specific action causes cost-sharing to apply to a wellness physical because an acute illness was also actively treated during the same visit.
What is billing a separate diagnostic Evaluation and Management (E/M) code alongside the preventive code?
For elective care, this type of authorization request is blocked after the service has already occurred, forcing the hospital to file a post-service appeal instead.
What is a retroactive prior authorization?
This fragmented, incorrect billing practice occurs when a coder bills multiple separate CPT codes for individual parts of a procedure that should be grouped under a single comprehensive code.
What is unbundling?
This specific legal document automatically overrides the industry standard Birthday Rule when determining primary plan layout for a child of divorced parents.
What is a court decree (or divorce decree/custody order detailing healthcare responsibility)?
What we can count on being posted in our Team chat, towards the end of our shifts, by Nick or Craig.
What is a corny timesheet reminder GIF? ;-)