TOOLS & RESOURCES
Name of e.Policies Virtual Assistant
What is Carmen?
Dual coverage claim when Medicaid is requesting reimbursement for their payment.
What is CRM111?
Dollar amount the provider and Aetna have agreed to for reimbursement purposes.
What is Allowed Amount?
Tab that should be reviewed to see what actions have been taken on a claim.
What is Audit Log?
End of year performance evaluation calculation method.
What is 50% delivery of business goals and 50% heart at work behaviors?
Resource that provides step by step walkthroughs for things not available in e.Policies.
What is Claim Resource Tool (CRT)?
Claim needs review for Mid-Level Practitioner Reduction.
What is CRM64?
Set of predetermined, fixed amounts, used for calculating reimbursements.
What is Rating System/Fee Schedule?
Tab in HRP where you can find member name, provider info, and address where services were rendered.
What is the Header tab?
5 heart at work behaviors include.
What is put people first, rise to the challenge, create simplicity, inspire trust, and join forces?
Database that houses Provider records.
What is Smart Front End (SFE)?
No contract found in HRP. Location, TIN, and contract verification needed in order to resolve this trigger.
What is CNT02?
Services or items that have special reimbursement handling.
What are Carve Outs?
Message codes can be located within this tab.
What is Line Tab?
Quality percentages for CBS.
What is 99% Financial Quality (Payment Accuracy)
97% Pay Incident
95% Total Claim Accuracy
Secondary System used for looking up
provider information.
What is Enterprise Provider Data Base (EPDB)?
Burgess processing error, pricing needed. Adding classification may resolve.
What is 416?
Supplier Location ID includes what 3 items
What is HRP Supplier ID, PIN Number, and Location ID?
EPDB Pin and Provider Specialty can be located within this tab.
What is UDT tab?
After clocking in for the day, the 7 things should be checked/completed on a daily basis.
What are Emails, New Day, Returns, Hadoops, MCAC Audits, PDS tracking, and Post Pay Audits?
3 systems that can be used to locate authorizations.
What is HRP, MedCompass, and Evicore?
Trigger code when provider doesn't have UDT Radiology Accreditation and trigger when accredited but billing for ineligible procedure and 2 Exclusions to workflow.
What is ADQQ and ADQR?
Modifier 26
Classification Exclusion List
Houses all contracts that are loaded into HRP.
What is Rumba (SCM) Strategic Contract Manager?
3 trigger colors in HRP and their meaning.
What is Red(Review and Repair)
What is Green (Warning Only)
What is Yellow (Warning Requires Review)
My Goal for the team is to help you all to become____- _______ ______.
What are Well-Rounded Processors?