MEDH / Referrals
The tool used by Medical Homes to coordinate care for our members.
What is a referral?
Name three groups who use the FCHN network for in-network benefits while in Washington.
What are:
Clackamas County, CollegeNET, Columbia Sportswear, OFC, SAIF, School District Trust or Umpqua Health?
The Facets default landing page containing a running log of all calls.
What is the General Task Page?
Has member # 100719841-00 used their wig benefit?
What is no
Knowledge Management System
What is KMS?
The task page in Facets that houses the name of the current Medical Home for a member.
What is the PCP Task Page?
The name of the network PEBB ProvChoice members use for in-network benefits in Oregon
What is ProvChoice?
Using member 100547219-02, the number of male, Dermatologists within 5 miles of zip 97306.
What is 10?
(as of 9/27/19)
The name of the extra network PEBB Statewide and SAIF members are able to use for in-network benefits in Oregon.
What is the OHSU network?
The section of KMS where relevant documents or guides can be found as they relate to a topic.
What is the references section?
What a Medical Home Provider ID starts with in Facets
What is MEDH?
What is the network would a Roth's member use if going to Legacy Hospital?
What is Universal PPO
Where we would search to figure out if a provider is participating for a member when a member has the provider name and the provider is located in Oregon/SW Washington. You may use member 100662614-00 if needed.
What is Facets - the provider button?
How many PTOTST visits does this member get per cyr? 112853052-00
what is no limit
The two topics in KMS where I find information about ambulance rides.
What are:
Emergent and Urgent Services & Transportation Services
aWhere the list of services that do not require a referral is found in KMS.
What is:
Referrals --> References --> Choice-Connect Referral Requirements
OR
Referrals --> FAQ --> What type of services do not require a referral on ProvChoice plans
Can a SAIF member go to OHSU?
What is yes
The items that need to be verified when a provider's office calls.
What are:
Provider name, Tax ID (or NPI), name of the person calling, members name, and member's DOB
What ded and OOPM would we quote for this family?112853052-00
What is family
The topic and scenario in KMS I look at to see what information needs to be verified when another insurance company calls on behalf of a member.
What is:
Confidentiality and Privacy --> Verification of the caller
The three main differences between a referral and a prior authorization.
What are:
A referral is to a person performing a type of service, a prior authorization is for procedures or non-participating providers
Referrals are entered as submitted and not reviewed, prior authorization requests are reviewed by HCS.
Referrals are only submitted by Medical Homes, any provider or member can submit a prior authorization request
The name of the network PEBB ProvChoice members can use in Arizona to avoid balance billing.
What is the First Health Complimentary network?
The names of the three different classification types Facets uses to cluster providers.
(Hint: P, F, G)
What are:
Practitioners, Facilities and Groups
What has this family met towards their OOPM?
What is $30
What KMS scenario would you use if looking to see what network requires PA's for an MRI?
What is Diagnostic Radiology