Alternative Care
Whether or not Massage Therapy is covered for SAIF members.
What is yes?
The HCPCS codes billed for medications relating to injections.
Hint: It's a letter..........
What are "J-codes"?
The healthcare reform influenced the way that contraceptive services were covered in this way.
What is "covered-in-full"?
The vendor we utilize to administer vision benefits for plans that have vision included.
What is VSP?
The department responsible for configuring Facets with the correct pricing for claims, benefit set up, provider networks, etc.
What is System Administration?
The number of visits a PHS WA member (113029006-00) has in a calendar year for Spinal Manipulation and Acupuncture combined.
What is 12?
BONUS: 7/12 are still available.
Where to look on the matrices and/or the benefits needed to quote for an in-office injection for member 113190776-00.
What are Injectable Medications(medication) and Outpatient Surgery & Services/Professional Services (administration).
The benefits needed to quote when an IUD insertion/removal is billed with a medical diagnosis.
What are:
Device: Durable Medical Equipment
Insertion: Surgery and Anesthesia
Removal: Surgery and Anesthesia
Whether or not MBR ID 112930793-00 has routine vision benefits.
What is we are not sure, so we would advise the member to call VSP for benefit information because vision benefits are separate from medical benefits.
The department responsible for being the liaison between the health plan and our participating/in network providers/facilities.
What is the Provider Relations department?
The PEBB plan that has a dollar limit for spinal manipulation and acupuncture instead of a visit limit.
BONUS: What is the limit?
What is the ProvChoice plan?
BONUS: $1,000 per calendar year
The place of service where Choice/Connect members must receive a Pneumonia: Prevnar Pneumococcal Vaccine.
What is at their Medical Home?
The diagnosis that needs to be billed for an IUD in order for it to be covered-in-full.
What is "contraceptive"?
Whether or not a visit to the Optometrist for a chronic dry eye issue would be paid under the routine or medical vision benefit.
What is the medical vision benefit?
The name of the letter sent to a member who needs to show proof of previous coverage with PHP.
*Hint: KMS Letters*
What is a CCC letter? (Certificate of Credible Coverage)
The benefit quote for member 100547288-00 who is receiving Acupuncture services from Dr. Bob Geno at Bob's house of Acupuncture and Tire Rotations.
What is $25 copay per visit, deductible waived up to the $2350/$1153.87 OOP max. Benefit limited to $1500/$0 per calendar year and is combined benefit including chiropractic manipulation, acupuncture, and massage therapy.
Member can see any willing provider.
The benefit quote for MBR ID 100696921-00 receiving code J1745 via infusion therapy at Providence St. Vincent Medical Center.
Hint: Don't forget to include PA information for that code!
What is: Outpatient dialysis, infusion, chemotherapy, radiation therapy
$250/$67.95 Ded, 15% coins up to $1500/$0 oop max
J1745 - Payable, PA required
Whether or not Plan B is CIF for member 112963002-00.
What is no, the member is over age 17 so this medication is OTC and therefore not a covered benefit.
Quote the benefits for MBR ID 100679340-00 going in to see Dr. Lance Anderson (1981 NW 185th Ave, Hillsboro) for an infection in her eye.
What are:
Specialist OV: $250 Ded/$0 $10 CP, up to the $1500/$10 OOPM
Diagnostics: CIF ded waived
The name of the letter we can send to members to show proof that they are currently eligible.
*Hint: KMS Letters*
What is a Still Effective Letter?
Whether or not Acupuncture was a covered benefit in 2017 for member 100725559-01.
BONUS: Why or why not?
What is no?
BONUS: This specific group chose not to adopt provider non-discrimination therefore they only covered Chiropractic and not Acupuncture.
The number of different medications injected into MBR ID 100233378-01 for DOS 02/20/18 with Dr. Anna Macasa.
What are 2? (2 J codes were billed)
The benefit for an office visit with Breanne Brown at PMG Bridgeport in Tigard for member 100589684-00 to discuss different birth control methods.
1. What is CIF with a contraceptive diagnosis
2. Ded waived, $20 copay up to the $3300/$0 OOP max for a medical diagnosis.
The vendor who has discounts available for eye exams and LASIK correction procedures.
Who is TruVision?
The billing cost center # when using an interpretation service for a call with a member.
*Hint: KMS*
What is 631?