QA Deductions from August
What is the limitation for Cardiac Rehabilitation?
3 sessions per week up to a 12-week period for a total of 36 sessions
What department sends a member verification letter?
Correspondence
What surgery is only covered through Blue Advantage with a Network Exception?
Spine
Call is about Effective/Eligibility dates only
Eligibility/Benefits - Eligibility
Who is the vendor for mental health/substance abuse?
Lucet
What must you confirm on ALL provider eligibility calls, even when the benefits are not given?
Network/Participation Status
What form does a provider fill out for a Network Exception?
Authorization/ Organizational Determination Request Form
What would be the copay for a Premier member seeing a PPO contracted Geriatric provider in office?
$35
Member needs password reset
My Blueprint - Password
Who is the vendor for a Health Savings Account?
Health Equity
For BTP's which colors are to be addressed, and which colors should be offered.
The ones in purple are to be addressed and the ones in black are to be offered.
What does DRG stand for?
Diagnosis Related Grouping
What are we required to say instead of "Hard Max"?
Limited Benefits
Calling to see how a claim has been processed
Claims-Status
Who is the vendor for pharmacy?
Optum Rx
Definition: Is the act of transferring a call to someone in a polite fashion by asking the caller to "please hold" and then announcing the caller to the person he or she wishes to be transferred to.
Warm Transfer
The timely filing for out of state providers?
Out-of-state contracted providers have 18 months, or based on their contract with the local blue, whichever comes first.
When is a $300 copay waived for an Emergency Room service?
If the patient is admitted into the hospital for In-Network or Out-of-Network services.
Member is trying to locate an in-network/Preferred provider; Member Needs to verify provider network status.
Provider Information - Participation Status
Who is the vendor for Fertility & Virtual Doula Services?
Kindbody
If a provider is calling to check the status of an Outpatient PA for cpt code 66984 and you are unable to locate the PA. What is your next step?
Check the cpt code in medical code Search
In what instances do we offer a Pre-Service Appeal?
Carelon (formerly AIM) denials are the only pre-service denials that an appeal will be accepted for.
Blue Advantage Walmart no longer requires a prior authorization for an Inpatient admission when?
When BAA is secondary to any other insurance.
When you transfer call to another area.
Redirect Call - Transfer
Who is the vendor when your back is broke?
Contigo Health