Claims
The tab within claims inquiry that holds the payment information and details.
What is the "Remittance Tab"?
The definition of a clinical edit.
What is a system denial due to incorrect coding and bundling and payment of certain CPT codes?
The benefits quoted for an outpatient surgery.
What are the surgery/anesthesia (surgeon) benefit and the outpatient surgery (facility) benefit?
What a member would submit (appeal or grievance) if they disagreed with a prior authorization denial.
What is an appeal?
The department that the COB team is a sub-department of.
What is OFT?
The reason why CL 150363954100 denied.
BONUS: Whose responsibility does it fall to?
What is "BAM - No AIM Prior Auth Obtained"?
BONUS: Provider Responsiblity
The line that line 6 is denying to on CL 152804301300.
What is line 5?
The age a member needs to be to have a screening colonoscopy covered-in-full. (For members on an individual plan or non-grandfathered group plan)
What is 50+?
The number of levels for an appeal that a fully large member has access to.
BONUS: What are the levels for?
What are 3 levels?
BONUS:
Level 1 - Member writes in
Level 2 - Grievance committee
Level 3 - IRO (external)
Whether or not the provider needs to submit their claim twice to Providence for a dual PHP member.
What is no?
The tab within claims inquiry which shows the second disallow explanation code applied to a claim.
What is the "Disallow Amounts Tab"?
What the provider can do for a CE denial of u16 that they disagree with.
What is rebill with a correct diagnosis code?
The modifiers billed to indicate it is an Assistant Surgeon claim.
What are modifiers 80, 81, 82 and AS?
The different ways a member can submit an appeal.
What are by mail, email or fax?
The information to obtain and route to the COB team for updates.
Look at the KMS scenario: Sending a CSI to the COB Team :)
The place of service code for 21.
What is "Inpatient Hospital"?
What the provider can do for a CE denial of z58 that they disagree with.
What is submit a clinical edit inquiry fax form?
*BONUS: What 2 things do they need to send with the form?
The charges/claim that an Additional Cost Tier copay applies to.
What are the professional charges?
The amount of time that PHP has to respond to a member's first level appeal.
What is 30 days?
The COB methodology used for all plans on the commercial team.
BONUS: Explain what it means.
What is the post-mandate method?
BONUS: The insurance companies coordinate benefits to reimburse the provider at the highest of the two contracted rates.
What we call the money that we keep for providers on a risk contract.
What is withhold?
The national network that does not have to submit a clinical edit inquiry form for clinical edits listed in KMS that they disagree with.
What is PHCS/Multiplan?
BONUS: What would you do if a PHCS/Multiplan provider called about a CE they disagree with?
The reason why CL 170674699600 applied to member responsibility and was not covered-in-full.
Why is the member under the age of 50?
The amount of time that PHP has to respond to a member's expedited appeal.
What is 72 hours? (NON business hours)
The place you would find notes from the COB team about a members coordination of benefits.
Where is Member Notes?