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Benefits
Referral
Intake
Claims
MISC
100

PRODUCT ID: B0TN0001

GROUP ID: TNONEX

What is the benefit for OP surgery done in the Office?

$0.00 Copay, 50% Coinsurance, Deductible applies 

100

What tab in facets can we locate the Referrals?

UM History

100

Does CPT 90838 for the state of CO require an Authorization?

Prior Authorization not required

100

For the state of CO what is the TFL for 1st level of appeal?

180 days from the Remittance Date

100

PDAT stands for?

Provider Data Aggregation Tool

200

How many hours are covered for Maternity IP stay? Both Vaginal and CS delivery.

48 for vaginal and 96 for CS

200

This is where we go to check more information about the referral.

Prospective UM

200

What services can we create a retro-authorization?

HHC and DME services

200

It is called a takeback of a payment from the provider

Recoupment

200

This is called the allowable amount of a service.

Medical Fee Schedule

300

PRODUCT ID: RGTX0000

GROUP ID: TXONEX

What is the benefit for the Specialist Office Visit?

$60.00 Copay, 0% Coinsurance, Deductible does not apply

300

Give 1 or 2 qualification/s for a referral exception?

Any of these:

  • The member had late or retroactive enrollment into the plan.
  • The member was given a paper referral by their PCP (no submission made to the plan).
  • The member needs follow up care as a result of an emergency room visit or inpatient stay.
  • The member is a new member with a chronic condition who has ongoing treatments with a specialist.
  • The current PCP was unaware of the plan’s referral requirements.
300

Where can we change the DOS on a pending authorization?

Services Tab

300

How do we compute COB payment?

UHC AA - OI Paid = UHC Paid amount

300

Fixed amount a member pays for a visit or prescription.

Copay

400

Where can we quote CPT 76977 with Dx Z82.62 when done in an OP Hospital?

Preventive Care Services

400

What states does not require any Referral for the year 2023

State of AL, KS, LA, MO, MS, NC, OK, and TN

400

For state of CO, what services can we create an authorization?

IP services for members that are head-on-bed/already admitted

400

Provider received a recovery letter from UHC. What is the address to send the refund check?

UnitedHealthcare Attn: Recovery Services

P.O. Box 740804 Atlanta, GA 30374-0800

400

It is expressed as a percentage on the amount paid by the member

Coinsurance

500

What platform can we use for Telehealth Behavioral? What is the phone number?

AMWELL (855) 635-1393

500

Member ID: 122136570

Is referral 801917803 valid for Dr. PHILLIPS, WHITNEY L. under Tax: 061786616? Explain. 

No, because specialty does not match even if they are under the same Tax

500

What do you call an authorization for OON providers?

Gap Exception

500

It is a law that applies to Out-of-network health care professionals at in-network facilities.

No Surprise Act (NSA)

500

What accumulates to the OOP?

Copay, Deductible, and Coinsurance.