Authorizations
COB Denials
Med Necessity/Experimental
Coding Denial
Potpourri
100
The process which involves a primary care physician to obtain permission from an insurance company before a patient can see a specialist or receive certain services.
What is a referral?
100
The meaning of COB.
What is Coordination Of Benefits?
100
The adjustment code used for medical necessity/experimental/investigational claim denials when all efforts have been exhausted and no further reimbursement will be issued.
What is MEDNECS (NOT MEDICALLY NECESSARY)?
100
The most common plan exclusion seen at Advanced Urology.
What is sexual dysfunction or infertility?
100
On Fridays, the AR team is responsible to give attention to these.
What is the Financial Review queue and the Missing EOB Spreadsheet?
200
The approval that some insurance plans require before they will cover the cost of specific medical procedures, hospital stays, or medications.
What is prior authorization?
200
The number of days, from the claim note date stating COB letter was sent to the patient, that an AR rep should allow before following up with the payer on the status of a COB update.
What is 14 days?
200
The steps taken when a claim billing CPT code 76770 denies based on an LCD policy.
1. What is check the Suppressed Errors on the claim?
2. What is adjust if a single dx is billed on the claim?
3. What is route claim for Coder Review if multiple dx are billed on the claim?
200
The documents sent to the payer when records are requested for a Urocuff claim billing unlisted code 55899.
What is the AU explanation letter for the use of Urocuff, the progress note and urocuff report?
200
The icon that indicates all saved files are syncing to the Share Drive when visible on your computer screen.
What is the blue cloud icon (OneDrive)?
300
The person/entity responsible for obtaining prior-authorization for a hospital visit/procedure.
1. What is the Advanced Hospital Team? - when the patient was scheduled by us.
2. What is the hospital? - when the patient was NOT scheduled by us.
300
The steps taken for this denial include to first to check the info screen to see if the insurance is different from what is on the claim. Secondly review patient documents to see if any recent scans of other insurance cards are present. Then check payer portal to see if any other insurance information is provided. Finally if no resolution can be found send claim to patient outreach for assistance.
What is MA04: Secondary payment cannot be considered without the identity of or payment from the primary payer?
300
Here is where you can research to find a specific policy with criteria for a procedure.
What is the payer website/portal for any payer clinical policies?
or
What is the Patient Experience Payer Policy Grid?
300
First steps when reviewing claim denial for inclusive and/or non covered.
What is review the fee pricer to see if we received the expected allowable and the payment poster approved adj code list?
Please note: if expected allowable is received, there is no need to go after additional reimbursement.
300
The Founder and President
Who is Jitesh Patel?
400
The authorization or referral number can be found on this tab in ECW.
What is the referral tab?
400
This step is taken after 14 days, and there is no resolution for the COB denial. COB has not been updated with payer and no response from patient.
What is flip claim to bill to patient? This is done to prompt patient to give us a call.
400
The important verbiage that should be added to an appeal when an experimental/investigational denial is received.
What is the payer policy criteria?
400
This procedure involves inserting a cystoscope (a thin, flexible tube with a camera) into the bladder through the urethra to visualize the bladder lining, followed by Botox injections into the bladder muscle to relax it. Prior authorization and meeting specific criteria are often required.
What is overactive bladder (OAB) and urinary incontinence?
400
The 3 different areas of the patients account to notate a plan exclusion to inform other departments of the exclusion for future visits.
What are the Account inquiry note, billing alert, and any upcoming appointments in the encounter screen?
500
The queue is where a denied claim is sent if follow up determines an authorization was obtained for a different CPT code, wrong Tax ID, and/or date than what was billed.
What is the Patient Access queue (Auth Admin Review status)? Please Note: only if your payer allows for a retro auth or update to an existing auth.
500
The procedure for this denial is to change insurance to Medicare as the primary payer, add the GW modifier to all codes billed and set for resubmission.
What is when patient is enrolled in Hospice?
500
These related procedures are used in the treatment of bladder and bowel dysfunction. One is a temporary, trial period while the other is the permanent implant.
What is the PNE (Percutaneous Nerve Evaluation) and SNS (Sacral Nerve Stimulation)?
500
Remark Code N640- Exceeds number/frequency approved/allowed within time period typically refers to. You can check this by visiting the CMS website.
What is an MUE (Medically Unlikely Edit)?
500
This is followed when it is more than 12 months from the final adjudication date of the claim, we must adjust off the balance after the estimated amount the patient agreed to pay originally (noted in billing notes).
What is The Advanced Patient Balance Billing Policy?