Eligibility
Can we NRP to Pt without a signed waiver for Eligibility denials?
Yes, refer to Bill to Pt TS
What date in Cactus and in Provider Finder indicates the provider is pending for credentialing?
01/01/2001
What does 26 modifier means?
Professional Component- is appended to aprocedure code to indicate that the serviceprovided was the reading and interpreting of theresults of a diagnostic and/or laboratory service.
Who decides the outcome of a prior authorization request
Clinicians
What is Column 1 and Column 2 codes?
When 2 CPTs are bundled, Colum 1 code is the primary code; Column 2 code is the secondary code which needs an unbundling CCI modifier.
How would you know if your filters are activated within a WQ?
A red slash through the filterfunnel icon, and it says “Showall”
What happens when the claim is processed out-of-network and the patient has out-of-network benefits?
This may result in the insurance payment being issued to the patient/subscriber
In billing US Breast Ultrasound, what does it means when a Z dx code is not in the primary position?
If a Z Dx Code is not in the primary position - The service is not considered a preventative screening. Instead, it is considered a diagnostic service and normal patient responsibility applies.
Do all medical services performed require prior authorization?
No. Prior Auths are usually only required for morecostly, involved treatments where an alternative is available.
In Radiology, give at least two common examples of modifiers to unbundle the 2 CPTs that are bundled?
Modifier 59 and XS.
What does Retro status inProf Tx Inquiry means?
VFO action had been performed to the claim.
Per pathway, if confirmed that the provider is actually INN and the service was rendered at a participating address but the insurance Rep refused to send back the claim for reprocessing, what should be our next step?
Request to get the specific reason why the denials occurred if it is not related to participation status (I.e. location issue, accreditation, certification) or send appeal when necessary
What is our resource when checking updates for all pending AR identified trends?
Open Items tracker
If there is no valid authoriation obtained for a services billes in POS 11,19, and 22? What is the next appropriate action?
If no Auth and No Waiver on file, perform adjustment
Where do we go in Encoderpro to look if diagnosis billed supports the CPT?
Crosscodes
What is the new plan replacement for Cigna Medicare this 2026?
Healthspring
Can we NRP the balance to the guarantor without a waiver, if confirmed provider is non-par?
No, a non-par waiver is required to NRP to the guarantor.
Which portion of the excerpt is considered findings? "Reviewed payment and adjustment history, CPT 70553 denied for invalid principal dx. Reviewed Encoder Pro found dx Z87.1 is not billable with denied CPT. Routed to Coding for review of new diagnosis.
CPT 70553 denied for invalid principal dx, DX Z87.1 is not billable with denied CPT.
If wrong provider was authorized but form the same department for POS 11 service, what is the appropriate action to take?
CMS stands for
Centers for Medicare & Medicaid Services
How Empire Plan should be loaded in the Registration Patient?
Two separate plans
BCBS – Empire Plan
NYS Health – Nys Health Insurance
If the provider is truly non-par, plan was loaded correctly, the payment was made to the patient, the EOB was obtained, signed waiver on file- how much should be billed to the patient?
The patient is responsible for the allowed amount on the OON claim. This will be the insurance payment and any OON copay/co-insurance/deductible.
Which is the only payer that requires billing 26 and TC for POS 11?
True or False: If a payor perceives a provider as OON they may deny the claim as "No Auth obtained instead of Provider not credentialed"?
Yes.
When an appeal is warranted?
Once thorough research is conducted and findings confirm aclaim was submitted according to reimbursable guidelines, astrong supporting argument including pertinent documents(records, policy information, authorization, etc) can besubmitted