Immunizations
The place of service where ProvChoice members can receive a Pneumonia: Prevnar Pneumococcal Vaccine and have it be covered in full.
What is their Medical Home, a participating pharmacy or another participating provider's office?
*Office visit copay may apply if administered in a providers office
The type of HCPC code 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 age/gender limits for the HPV vaccines, SPECIFICALLY types 16 and 18.
What are females 10-25 years of age only?
The benefits needed to quote for an in-office injection.
What are "Injectable Medications" and "Surgery/anesth (in office)"?
BONUS bragging points: If you included an office visit benefit as well!
The 5 groups that are religiously exempt from covering contraceptive services in full.
What are:
1. Oregon Catholic Press
2. Franciscan Montessori Earth School
3. Mt. Angel Abby
4. Archidiocese of Portland
5. LaSalle Catholic Press
Whether or not MBR ID 100246056-00 has routine vision benefits.
What is no? (Rider is grayed out)
The department responsible for being the liaison between the health plan and our in-network providers/facilities.
What is Provider Relations?
The age a member needs to be in order for no PA to be required for a Shingrix/Shingles vaccination.
What is 50?
The benefits needed to quote an infusion done as outpatient at a hospital or facility.
What is the "Outpatient surgery, infusion, dialysis, chemotherapy, radiation therapy" benefit?
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 MBR ID 100948999-00 has routine vision benefits.
Hint: Pay attention to the type of plan........
What is no? (Standard plan - member is over the age of 19 - therefore no adult vision benefits)
The name of the letter sent to a member who needs to show proof of previous coverage with PHP.
What is a CCC letter? (Certificate of Credible Coverage)
Whether or not Yellow fever vaccine is a covered travel vaccine for PHS OR members.
What is yes, it is a covered travel vaccine for PHS OR members.
The benefit quote for MBR ID 100129262-00 receiving an in-office injection for J1720.
Hint: Don't forget to include PA information for that code!
What is:
OV: $15 CP, ded waived, up to $2000 oopm
Inj Med - $500 ded, 20% coins, up to $2000 oopm
Surgery & Anesth - $500 ded, 20% coins, up to $2000 oopm
J1720 - Payable, no PA required *QPAD*
The benefit(s) that apply for grandfathered plans for Implanon/Nexplanon.
What are:
1. Device: DME
2. Insertion: Surgery benefit
3. Removal: Surgery benefit
Quote the benefits for MBR ID 112832139-00 (gr # 107979) going in to see Dr. Lance Anderson (185th Ave, Hillsboro) for an infection in her eye.
What are:
Specialist OV: $15 CP, deductible waived, which applies to the $2000 OOPM
Diagnostics: 10% coinsurance, deductible waived, which applies to the $2000 OOPM
The name of the letter we can send to members to show proof that they are currently eligible.
What is a Still Effective Letter?
Certain immunizations are not covered due to these purposes for the ASO Other groups. (WHY the member is getting them done...)
What are "Immunizations/Vaccines for Travel, Work or School"?
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 HCPC code billed for a Skyla IUD.
*BONUS: Does it require a PA?
What is J7307?
*BONUS: No, IUD's do not require PA's.
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.
What is 631?