Claims and Coding
The payer ID that Dr. Melinda Marks (Jefferson St, Boise, ID) would send a claim to for MBR ID 100129262-00. Her clearing house is ZirMed.
What is: PHP01?
The definition of a clinical edit.
What is a system denial due to incorrect coding and bundling and payment of certain CPT codes?
The CPT code range billed for surgeries.
What are 10000-69999?
The name of the application used in Facets to read notes on a prior authorization.
What is Prospective UM?
The type of providers that typically perform colonoscopies.
What are internal medicine doctors or gastroenterologists?
The tab within Claims Inquiry that houses a second disallow explanation applied to a claim.
What is the Disallowed Amounts Tab?
The clinical edit applied to CL # 180296208800.
What is z60 - Not a Primary Diagnosis Code?
The benefits needed to quote to a member an outpatient surgery.
What are surgery; anesthesia (professional/surgeon claim) and outpatient surgery (facility claim)?
What the UM in Prospective UM stands for.
What is Utilization Management?
The age a member needs to be in order for a colonoscopy to be CIF in-network.
What is 50+?
The address AND fax # where Dr. Charles Pollick (Wilshire Blvd, Los Angeles, CA) would submit a claim for MBR ID 113176539-00.
What is: PO Box 3125 PDX, OR 97208 or 503-574-5940?
The payment policy referenced with clinical edit u13.
What is Payment Policy 13.0?
The modifiers that can be billed indicating an assistant surgeon claim.
What are: 80, 81, 82 and AS?
BONUS Bragging Points: What types of providers are NOT covered as an assistant surgeon?
The subsection (in open work) within Prospective UM that CS needs to go to find information about authorizations.
Example MBR ID: 100251477-00
What is the History Subsection?
Whether or not a PA is required for a diagnostic colonoscopy being done in an ASC (Ambulatory Surgery Center).
What is yes?
The address, fax # and payer ID where Dr. Peter Albro (7th Ave, Seattle, WA) would submit a claim for MBR ID 113203242-00.
What is:
Attn: FCHN
PO Box 2289
Seattle, WA 98111
Fax: 206-268-6181
Payer ID: 91131
What a provider can do for denial on CL 180666025000.
What is rebill with a more specific diagnosis code?
When quoting surgery benefits, this is one thing we always *ALWAYS* ask for in order to check if a certain something may be required.
What is the CPT code?
The note on the denied PA for MBR ID 113240413-00, Gregg Corey, for reference ID 003323495.
What is: "CALL FROM GREGG (MEMBER) WANTS DENIAL LETTER FOR AUTH 003323495 EMAILED TO HIM SO HE CAN GIVE IT TO HIS DR, ADV WE CANNOT SEND EMAILS AND TO HAVE DR'S OFFICE CALL AND REQ LETTER TO BE FAXED TO THEM."
The modifier that a provider bills to indicate that a colonoscopy started out preventive, but turned diagnostic.
What is modifier 33?
The TWO places that a CSR can look up explanation code definitions.
What are:
1) KMS > Explanation Codes
2) Facets > Applications Menu - Application Support > Explanation Codes > CSR must scroll through the list to find a specific code
The decision made for a clinical edit denial for MBR ID 113259241-00 on DOS 10/13/18 for Dr.Timothy Pederson.
What is upheld?
The benefit quote for MBR ID 113059446-00 to get a knee replacement. (In-network)
What are:
Professional: $2500 deductible, $500 CP, then a 30% coinsurance which apply to the $7900 OOPM
Facility: $2500 deductible, 30% coinsurance which applies to the $7900 OOPM.
The latest note information on PA denial for MBR ID 113282099, Johnny Bannon, for reference ID 003319599.
What is: "Provider reconsideration recvd 01/10/19. Entered appeal 190111000009.
The colonoscopy benefit for MBR ID 100118505-00.
What is:
Surgery; anesthesia in an office or facility: $100 deductible, 10% coinsurance which applies to the $1200 OOPM.
Outpatient surgery: $100 deductible, 10% coinsurance which applies to the $1200 OOPM.
Labs: 10% coinsurance, deductible waived which applies to the $1200 OOPM.