Referrals
Whether or not physical therapy at a Providence hospital requires a referral from the medical home for member 100701175-00.
What is no, a referral is not required for PT/OT/ST.
Whether or not the Salem Clinic is a seamless access provider.
What is yes?
The topic name in KMS that houses xray and lab information.
What is the Diagnostics topic?
A discipline that aims to promote health by enabling people to perform meaningful and purposeful activities.
What is Occupational Therapy?
The name of the vendor who generates ID cards.
What is Clarity?
The standard review time for a referral through PMG.
What is 14 business days from the date of the medical home request?
The covering provider criteria.
What are the providers must be in the same network, have the same specialty, and practice under the same TIN.
The CPT code for puncture of a vein (ex - blood draw).
What is 36415, venipuncture?
Whether or not an office visit to a Physical Therapist requires a referral for the ProvChoice plan.
What is no, no referral is required.
The path to get to the 2018 Swedish PPO matrices.
What is P: drive --> PASO --> Implementations --> 2018 Implementations --> Swedish --> MATRICES --> 2018 Swedish PPO
Or
KMS --> Providers and Networks --> Swedish LOB --> Contacts and Resources --> 2018 Swedish Matrices --> 2018 Swedish PPO
Using member 112929486-00, whether or not referral 181060250 is still a valid referral for office visits with Dr. Kappler.
What is yes, it is valid through 4/6/19 and has all six office visits available.
The three areas in Alaska where all out of network specialists and PCP's are paid "As If" they were participating providers.
What are Kodiak, Seward and Valdez.
Whether or not the lab claim will pay in network if the blood is drawn in a participating providers office and sent to a non-participating lab.
What is the claim will pay in-network because we do not penalize the member for something outside of their control.
The number of PT/OT/ST visits a PHS OR member receives each calendar year.
HINT: KMS
What is 75 visits?
The types of providers who can perform an Annual GYN exam for member 112855200-01.
Who are PCP/PPP's, GYN, OB/GYN, PA's, ARNP's, CNM- Certified Nurse Midwives and Naturopaths.
This is an Intel member.
Whether or not Dr. Brian Moyers in Portland can submit a referral for member 112929486-00 to see Dr. Joseph Pinter in Portland.
What is no, the referral would have to come from the member's medical home on file - Providence Medical Group - North Portland.
Whether or not Jennifer Moe, a General Practice provider in Kodiak, AK would be paid "as if" she were participating with PHS Premera.
May use member 113190668-00 if needed
What is yes, Kodiak, Valdez and Seward are underserved areas in Alaska so all providers in those areas are paid "as if" they are in network.
The two modifiers used on facility and professional radiology claims.
What are TC and 26?
Using member 113015662-00, the nearest Tier 1 Physical Therapist to her home address.
Who is Rob Jensen, PT?
The names of Tracy's two boys and Brooke's dog.
Who are Luke, Jace and Mika.
Using member 100715828-00, whether or not referral 180250149 is still valid and if it can be used for an office visit with Dr. Andrew Chen.
HINT: TIN 680637976, KMS Covering Provider rules
What is yes, Dr. Andrew Chen is a covering provider for Dr. Brian Erickson. They practice under the same TIN 680637976, have the same specialty Oncology/Hematology and are participating within the same network ProvChoice. Referral 180250149 is valid until 1/25/19 and has 23/25 office visits available.
Whether or not Robert Bentley from Eye Health NW on Northrup St. in Portland would be a seamless access provider for member 112929486-00.
What is yes, the member has a PMG medical home and so seamless access would apply for the group of Eye Health NW providers practicing under TIN 931014730.
For claim 162805079300, whether or not this is a professional fee or technical component claim.
*BONUS* How do you know?
What is a technical component claim?
*BONUS* (bragging points) The claim is from a facility and has a TC modifier on it.
Whether or not a member would receive twice as many PT/OT/ST visits if they are covered under two Providence insurance plans.
HINT: KMS
What is no, the visits accumulate together under both plans. Ex - prime plan has 75 visits, secondary plan has 60, member would only get a total of 75 visits for that calendar year.
Whether or not we can tell a subscriber on a Intel plan if his wife who is covered on his plan has met her deductible and how many PT visits she has left if I do not have consent to speak to him. Where did you find this information?
What is no, we are not able to give him this information. See KMS --> Confidentiality and Privacy --> Scenarios --> CALLER: Subscriber/Member ABOUT: Another covered adult on the same plan --> Exclusions --> Available benefits and Amount met on accumulators