Claims
The fax number used to submit claims.
What is 503-574-5940?
The vendor responsible for DME distribution for our members in Oregon and SW Washington.
*Bonus: What is their phone number?
What is "Providence Home Services"?
*BONUS: (503) 215-4663
The department that the COB team is a sub-department of.
What is "OFT"?
The vendor used for our alternative care network.
What is "ASHN"? (American Specialty Health Network)
Healthcare Reform impacted how we cover prenatal visits in this way.
What is "covered-in-full"?
The Place of Service code for 21.
What is "inpatient hospital"?
The location code/place of service code which indicates "Patients Home".
What is "POS 12"?
Whether or not the provider needs to submit their claim twice to Providence for a dual PHP member.
What is no?
The benefits needed to quote for a member calling for acupuncture benefits.
What are: "Acupuncture benefits, OV to an alternative care provider, xrays/labs and outpatient rehab"?
The benefits quoted to a member calling about maternity.
What are: prenatal visits, delivery/postnatal visits, diagnostics (labs/ultrasounds), inpatient hospital (facility), routine newborn nursery care and/or circumcision in the provider's office.
The tab within claims inquiry that shows the secondary disallow explanation code applied to a claim
What is the "disallow amounts tab"?
The dollar limit for foot orthotics for MBR ID 100480534-00.
What is "$200 per calendar year"?
The information to obtain and route to the COB team for updates.
Look at the KMS scenario: Sending a CSI to the COB Team :)
Whether or not an Alternative Care Provider is required to send notification to EviCore.
What is no?
True or False: Home Water Births are covered for a Small Group member.
What is False?
The reason why line 2 on CL # 180306236801 denied.
*BONUS: Whose responsibility does it fall to?
What is "not a covered benefit"
*BONUS: Member responsibility
The benefit that lancets and test strips fall to for members with diabetes.
*HINT: Diabetic supplies or DME?
What is the diabetic supplies benefit?
The COB method used for Commercial.
*BONUS: Explain the method.
What is "post mandate"?
*BONUS: Providers are reimbursed up to the highest allowable between the two insurance companies.
The vendor we can refer member's to if they do not have alternative care benefits.
What is "Choose Healthy"?
The two types of breast pumps covered.
What are hospital grade and commercial grade?
What we call the money that we keep for providers on a risk contract.
What is "withhold"?
The POS that needs to be billed for HCPC code A7034 to be covered.
*BONUS: Is a PA required?
What is "POS 12"?
*BONUS: No PA is required
The place you would find notes from the COB team about a members coordination of benefits.
What is "member notes"?
Quote the in-network chiropractic benefit for MBR ID 112874335-00
CHIRO MANIP: DED WAIVED $25 CP - DOES NOT APPLY TO OOP. COMBINED WITH ACUP, LIMITED TO 3 VISITS COMBINED PCYR
OV ALT: DED WAIVED $5 CP UP TO OOP $750
MODALITIES/PT: 100 DED, 5 COINS, UP TO OOP $750, LIMITED TO 30 VISITS PCYR COMBINED WITH OT/ST
XRAYS: DED WAIVED, 5 COINS UP TO OOP $750
Describe what "Global" means when a provider bills a pregnancy claim.
**HINT: Check KMS
The physician provides care to the member throughout her pregnancy and then bills a single rate for all pre-natal visits, the delivery and post-natal visits.