Name that Requester Type
Claims Attachment is your Purpose of Use
Insurance Payment Requester Type
The default Purpose of Use for the Insurance Payment requester type if no purpose has been cited on documents
Claims Attachment
Assigned to Insurance Payment requester type with no Purpose cited on documents - what POU do you select?
Claims Attachment
CDC / COL / TRC
What is your POU?
HEDIS
Records are going to Datavant/CIOX on behalf of Cigna for a Commercial Risk Adjustment Audit - what is your Requester Type?
Other Billable Requester Type
Pre-Payment Audit is your Purpose of Use
Insurance Payment Requester Type
Records are being collected for all patient's seen at Facility with the COL measure
HEDIS
Per authorization form, patient is applying for Short Term Disability with AFLAC - what Purpose of Use would you select?
Disability Insurance
Confirming Medical Conditions of Patient- DOB year 2007
Commercial Risk Adjustment
Records are being sent to the local Social Security Office based on patient-initiated authorization - which requester type would this get assigned to?
Government Requester Type
Medicare is your Purpose of Use and records are going directly to Anthem BCBS
Payor Requester Type
This Purpose can be used when the documents indicate records are needed prior to payment for audit purposes
Pre-Payment Audit
UHC is requesting records from the past two years for patients seen under the CDC measure at that Facility to verify the accuracy of the previous HEDIS audit - what POU would you select?
RADV
Needs to confirm diagnosis codes used for accuracy
Medicare Risk Adjustment
Livanta is requesting records for a QIO (Quality Improvement Organization) or Quality Review purpose - what Requester Type would this get assigned to?
Government Requester Type
AFLAC is requesting records in order to access patient's coverage under their Supplemental Health Ins.
Insurance Requester Type
Records are being sent to Independence BC in order to confirm patient's medical conditions
Commercial Risk Adjustment
Facility needs to send records to Health Insurance Co to show medical necessity for treatments - what POU would you select?
Appeals
Prior to Payment - auditing bills for accuracy
Pre-Payment Audit
When Facility asks us to send records to Health Insurance Co on their internal letterhead/form - what do we call this type of request?
Facility Initiated
BCBS is requesting records due to a complaint they received from a Medicare patient - what requester type would this be assigned to?
Payor Requester Type
Documents cite beneficiary is filing to collect on behalf of deceased parent - what purpose of use would that fall under?
Life Insurance
Guardian Life Insurance is the requester per authorization and Purpose of Use selected on authorization is "Other" - what POU would you select?
Life Insurance
Validating previously completed audit
RADV
Why are Pre-Payment Audit purpose of use requests assigned to the Insurance Payment building and not Payor?
Payor is for paid claims to be audited
Insurance Payment handles all claims prior to payment or payment disputes