Systems
the module in QNXT where we document our calls
What is Call Tracking
the 3 benefits provided to all OHP Medcaid members
What is physical, dental, and behavioral health?
the 3 pieces of Provider information that need to be verified on every call
What is Caller name, Name of Facility/Clinic/Physician, and phone # of the Facility/Clinic/Physician
PCS
Provider Customer Service
the payer of last resort when members have dual coverage
Medicaid
the system that can help us with Eligbility discrepancies
What is MMIS?
how to tell if a member's eligibility in QNXT is current
What is no termination date? (blank termination date?
a Provider can give this piece of information in place of a Member ID or Medicare ID #
What is last 4 of Social Security number?
HSO
HealthShare of Oregon
explain what a DMAP is and why is it important?
it's a registration number with the state of Oregon, and if Providers want to be paid for services rendered to members, they have to have a DMAP ID
a CareOregon system where we can look up members' Physcial and Dental plan assignments
What is COWA?
Look up Member in QNXT and identify the following information based on what you can see there:
Member: VB900O9X
CCO:
Medicare or Medicaid?:
Plan Type:
Dental Plan:
Medical Plan:
True or False: we can share information that is not found in QNXT and COWA with verified Providers?
FALSE
JCC
JacksonCare Connect
Explain the difference between Call Tracking and Call Routing
Call Tracking: happens on all PCS calls; it is your notes outlining who you spoke to and what the call was about
Call Routing: when a call issue has not been resolved and someone from another department needs to take a look at the account
the Provider portal
Connect
Look up Member in QNXT and identify the following information based on what you can see there:
Member:TT100K6B
CCO:
Medicare or Medicaid?:
Plan Type:
Dental Plan:
Medical Plan:
True or False: we can discuss information about one facility/physician/clinic to another
FALSE
COB
Coordination of Benefits
explain the difference between credentialing and contracting
credentialing: is required to be contracted with CO; CO checks licences etc
contracting: a legal agreement between provider and insurance to get paid a certain amount for certain services
what do we need to remember about the termination date showing for plans in COWA?
COWA only shows current eligibility, not future, so it was always mark plan termination as the last day of the current month. Do not let it fool you into thinking the plan has termed! Instead, if you do not see a V or a T, the plan is active.
Look up Member in QNXT and identify the following information based on what you can see there:
Member:IR301V7M
CCO:
Medicare or Medicaid?:
Plan Type:
Dental Plan:
Medical Plan:
the tab in QNXT we use to verify HIPPA at the beginning of all PCS calls
What is the Summary tab in Member module?
what does each equate to:
CMS:
DMAP:
CMS: Medicare
DMAP: Medicaid
Explain Non Par vs Par & then explain what "Non Par No Pay" is.
Name 3 Non-Par No Pay Provider types:
Non Par: not participating; no contract with CO
Par: participating; has a contract with CO
Non Par No Pay: certain specialities require providers to be contracted to recieve payment.
Choose 3:
optometry
Pphthalmology
Acupuncture
Chiropractic
Physical Therapy
Occupational Therapy
Speech & Hearing Therapy
Dental
General Outpatient BH &SUD/BH services that do not require auth