Hearing
Our in-network hearing aid provider.
What is Truhearing?
The vendor we use to administer our mental health/chemical dependency benefits and process these claims.
What is PBH/Optum?
The provider types that can deliver babies.
What are family practice (vaginal deliveries only), OB/GYN's (vaginal or cesarean), Certified Nurse Midwife, CNM (vaginal deliveries only), High Risk-Perinatologist or Neonatologist (vaginal or cesarean), any class of licensed health care practitioner acting within the scope of their state licenses, Licensed Midwife (vaginal deliveries only) and Licensed Direct Midwife (vaginal deliveries only)?
True or false: There is automatic enrollment and coverage for newborns for an individual member.
What is false?
The modifiers that may be billed with a sleep study claim. (Hint: these apply to all diagnostic radiology tests...)
What are modifiers 26 and TC?
Where members can obtain hearing aids.
Where is an audiologist's office or DME vendor? (Truhearing)
The two claim statuses that apply to a mental health/PBH claim.
What are 81 and 89?
Whether or not ultrasounds fall to global maternity billing.
What is no? It falls to the member's diagnostic benefit.
The length of time subscribers typically have to enroll a newborn onto their employer-sponsored group plan. (OR-LG).
What is 60 days from the DOB?
Whether or not a PA is required for a home sleep study.
What is no?
Whether or not MBR ID 113149158-00 has hearing aid coverage.
What is no?
Where a PA request gets sent for services relating to mental/behavioral health or chemical dependency.
Where is PBH?
The maternity benefit quote to MBR ID 100505068-01.
What is: Let me here those benefits :)
The two types of breast pumps covered on the commercial team.
What are hospital grade breast pumps and commercial grade breast pumps?
The modifier billed indicating a rental.
What is RR?
Information needed to provide to Truhearing when conference calling with a member.
What is:
Member ID/Name
Member in-network DME benefit
Member in-network specialist OV CP
DED/OOPM accumulators along with HA limit and whether it's been used or is still available.
CSI # for reference on both ends
*Phone # is also helpful in case the call drops during the transfer
The name of the reference document which houses information on difference in financial responsibility between the health plan versus PBH.
What is "Division of Financial Responsibility Between PHP and PBH"?
Provider is billing for delivery plus postpartum care. Tell me whether or not this falls to global or non-global billing.
What is partial/non-global billing?
True or false: A member can purchase a hospital grade breast pump.
What is false? The member can only rent for the duration of the breastfeeding.
The modifier billed indicating a DME purchase.
What is NU?
Whether or not MBR ID 112960846-00 is currently eligible for their HA benefit limit.
What is no? The last HA claim on file is 01/16/19, the limit is one per ear every 4 calendar years.
Whether or not a covered parent calling on a dependent child who is 15 year old, and they have consent on file with PHP, can PBH talk to the parent about the child.
What is no? The parent must fill out a consent form.
The payment policy related to maternity billing.
What is Payment Policy 7.0?
BONUS Bragging Points: Show me where the payment policies are housed online.
The process in which PHP follows when receiving a claim for a newborn not yet added to the plan.
What is pend it on the mother's account? Once the baby is enrolled, the claim would close on the mom's account and would be transferred to baby's account and then processed.
The PA requirements around code E0601.
What is: PA required for first 3 months to rent; after 3 months, before it converts to a purchase, another PA is required, and compliance information is reviewed ?