Claims
The term EOB stands for
Explanation of Benefits
IQ1300
This product is a commercial HMO benefit plan using network providers/service.
Ambetter by Superior HealthPlan
Inquiry questioning an auth related denial for LTSS services, and you are able to find an auth in TruCare Cloud, however, the auth did not cross over into Amisys.
CAT Team
Responsible for Trial Check Runs and perform post-production CR Audits.
COA
A provider should submit these items with their reconsideration or appeal
All applicable documentation/medical records and the Reconsideration Request Form/Appeal Form
PR0300
Provider Affiliation
Medicaid Managed Care program servicing low-income families at no cost to them
CHIP
Responsible for generating and sending recovery notification letters to providers when a claim recovery is needed.
Recovery Team
Creates and submits Change Requests (CRs) for Amisys configuration.
CIA
corrected claim considered
a Reconsideration
IQ3400
Fee Schedule
Medicaid Managed Care program, integrated delivery of acute and long-term services and support, for children and young adults aged 20 and younger.
Star Kids
Responsible for pended inventory, adjustment requests, correspondence, appeals, and projects.
Claims Shop
Responsible for reviewing inquiries and creating projects for the reprocessing of claims.
Claims Liaisons (CL)
Screen used to lookup code set information
RF0300
IQ0200
A fully integrated Managed Care model for individuals who are enrolled in Medicare and Medicaid. The goals of the Dual Demonstration are to have one health plan be responsible for both Medicare and Medicaid services, improve quality and individual experience in accessing care and promote independence in the community.
MMP
Responsible for building and implementing the behavioral health business rules so that BH claims auto-adjudicate correctly.
Configuration
Responsible for tracking interest for the Medicaid line of business, and for reviewing and responding to internal audits.
Review Division
a mini payclass and also contains configured PSQs that Amisys recognizes first
Except Fee
RF0300
Code Set Detail
program is a health insurance designated for children whose families earn too much money to qualify for Medicaid, yet cannot afford to purchase private health insurance
CHIP
receive an inquiry that states a provider's claims are denying as non-par and they should be par, and you have researched and see that there is a contract for the provider,
Claims Support - Provider Setup/Configuration
Maintains pre-adjudication scrubs
Encounters