Authorization
Approval obtained from insurance payer before providing items or supplies
Prior Authorization
What document has the patients name, DOB, diagnosis, length of need, HCPCS, quantity, physicians printed name, signature, date, and npi?
The payer confirms there is no claim on file, and the claim has never been submitted. What should you submit?
Initial Claim/ Fresh Claim
Where in Brightree can you verify the pricing assigned to a payer?
Price Table
What code identifies the DME item or supply being billed?
HCPCS
Approval obtained from the insurance payer after providing items or supplies
Retro Authorization
Proof of delivery
A claim was processed with the wrong number of units. The payer allows you to fix the original claim. What should you submit?
Corrected Claim
Before comparing pricing, what must match between the invoice and price table?
HCPCS Code
What two-character code provides additional information about a billed HCPCS?
Modifier
A claim denies for authorization. Authorization on file is for August 1-31. Date of service is September 5th. Can we use this authorization
No - expired
What document confirms a patient approves supplies to be shipped? Where to find?
Refill Authorization > connect tab or reorder notes
Original Medicare denies a DME claim. You disagree with the decision and request the first level of appeal. This is called ______.
Redetermination
The HCPCS and modifier match, but the invoice price differs from the assigned price table. What should you investigate?
Pricing Discrepancy - fee schedule, provider manual
Which modifier identifies a new DME equipment purchase?
NU
A claim denies for missing authorization. Brightree shows an active authorization covering the DOS, but the approved HCPCS differs from the billed HCPCS. Can we use this authorization?
No - HCPCS mismatch
What documentation do you need if a medicare or medicare advantage patient is receiving A4353 - In addition to the POD, Rx, PN, Refill?
Medicare upholds a denial after redetermination. You disagree and request an independent review by the QIC. This is called ______.
Reconsideration
You discover multiple invoices with incorrect charges caused by an outdated price table. What should you request?
Price Table Update
Which modifier is not covered?
XX
A claim denies for missing authorization. You verify the approval matches the patient, HCPCS, and DOS. The payer confirms the authorization number was omitted from the original claim, refuses reprocessing, and requires a replacement claim. What are the next steps?
Link PAR
Add PAR number to box 19
Submit a Corrected Claim
What documentation for a Medicare wound care patient? How often do we need new orders?
Wound Care Documentation - size, debridement, slough, stage, etc
3 months for medicare, wound care assessment should be within 1 month.
A commercial payer denies a wound care claim for medical necessity. Your reconsideration was upheld despite supporting medical records. The payer allows another formal dispute. What should you submit?
Appeal
We do not do ALJ hearings ***
How do you get a price table updated?
Email Liz/ Ashley with all of the information and links to show where you found the correct information or reference numbers of your call.
Which modifier do we use if a patient is in hospice?
GW