Auths/Referrals
Code Edits
IRT
Member Responsibility and Balance Billing Procedures
Random Questions Here
100

What Does PFP Stand for? 

Physician Finder Plus

100

What Platform do we review on the Code Edit Explanation Code List

CAS

100

Name 3 documents that are required to be attached to the case/efile before sending to IRT. 

IRT Checklist

Chapter 3 EOC

Resolution Letter

Complete EOC



100

What document is needed to determine if a member has met their MOOP or Deductible.

Deductible Spreadsheet

100

Which Vendor do we send PDPM reviews to.

Navihealth
200

What modifier do you use on the MHI screen in CAS to determine if there is an Auth/Referral linked to the claim. 

R Modifier 

200

Name 3 Vendors

ClaimsXten (CXT)

Cotiviti PPM/CV

Optum (OPT)

LCD/NCD

200

What is the correct subtask used if the denial is a Code Edit Denial. 

IRT Initial Review Code Edit Review

200

What is reviewed to determine whether the correct Cost-Share is applied.

Evidence of Coverage (EOC)

200

Name 3 places you can locate the member's PCP

Blue Banner

J Modifier 

CI/PAMG

300

What document do you review for the denial code, to determine if the denial is stating that the Auth/Referral was Not received, Not matched or Not approved. 

CAS Deny, Mpay, and Pend Codes Master

300

ClaimsXten: What modifier do you use at the end of the MHI screen to check to see if there is a referring claim causing a denial on the appealed claim. 

Modifier HGM

300

True or False

If the Subcategory reflects other, than an explanation should be added in a case note.


FALSE

300

True or False:

Once 3 outreaches are made to the member to explain the outcome of the balance billing case can be dismissed.

False: Only 2 outreaches are needed

300

True or False

You can use the CAS Deny Master Document to assist with Sub-Category Options 

True

400

Which member plan may direct you to review the Prior Authorization List (PAL)

PPO Plan

400

Name two Business Partners that may need request for additional review for the code edit on the claim. 

MCCAU and CEVM

400

True or false

7-10 business days are needed for cases due under day 50. 

False

400

True or False

If the accumulations determine that the member is over their MOOP/Deductible limit, the next step is to submit to CRU for reprocessing.

False: A Ticket needs to be created

400

What procedure is reviewed for appeals involving (just to name a few) work related, vehicle, assault injuries. 

Subrogation

500

True or False: 

If the approved referral is for the same group as the facility provider on the claim image, this is a match when the service and date of service (DOS) match.

False

Has to be the Billing Provider

500

What is the purpose of having the Code Edit Procedure in Place.

*To identify when incorrect procedure code combinations are reported.

*Reduce and eliminate improper claim payments

500

What needs to be attached to the case when reviews are completed by the MD.

Documents cited by the MD

500

If a Non-Contracted provider is billing the member, then what needs to be determined.

If they accept Medicare assignment.

500

What are two places you can locate an approved or denied authorization for a claim.

CGX and PRI Screen in CAS 

M
e
n
u