M&R
What guidelines do we follow?
We follow Medicare Guidelines.
What is the standard turnaround time for authorizations?
5-14 calendar days
These are services that help find out why you are having trouble getting pregnant.
Infertility Services
This is medical services that include: prenatal, delivery, postnatal, and pregnancy complications. We cover these services provided by a doctor, nurse midwife or nurse practitioner. This also includes prenatal, labor and delivery for dependent child.
Maternity Services
Where do we check authorization requirements aside from PA Check?
PNL - Provider Notification List
This is an in-patient rehabilitation and medical treatment center staffed with trained medical professionals. They provide the medically-necessary services of licensed nurses, physical and occupational therapists, speech pathologists, and audiologists.
Skilled Nursing Facility
What Benefit Category would you check for drugs administered by the member itself?
PBM - Pharmacy Benefit Manager
PNL says Authorization is not required, but based on PA check Medical Necessity requires Prior Authorization. The code and diagnosis depends on medical necessity. What would you do?
Create Prior Authorization
This is a requirement that physicians, other health care professionals, non-facility providers, or facilities notify us before performing services related to certain services or procedures.
Authorization or Notification
What tool do you use when faxing a document to Providers?
RightFax
What are the questions needed to be asked when expediting the case? (give one)
1. Will this jeopardize the members health?
2. Is this life threatening?
3. Is the member in extreme pain?
This is the name for Allergy Services for Policy 2006 and below.
Injection
Provider is looking a benefit for the code 43645. Where would you quote this? This is going to be rendered inside a Hospital.
Hospital - Inpatient Stay
It's routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Preventive Care Services
Where do you check the codes if it's valid and billable?
Knowledge Library
Where do we check for benefit accumulation for M&R?
CPA Tool
The provider is asking authorization for INN coverage even though they are OON. This type of scenario falls under _______.
GAP Exception
Give at least 4 types of Therapy Benefits.
Physical
Occupational
Speech
Cardiac
Pulmonary
Chiropractic
What is the timeframe for admission notification?
within 24hrs or by 5pm the next business day on weekends and holidays
Where do we check if the medicine is available for buy and bill?
CSAL
What is our preferred lab? (provide one)
Lab corp / Quest
What are the requirements for the member to be eligible to have services in any part of the country?
Passport
Give at lease 3 Benefits that you would quote for Maternity Benefit.
● Physician’s Office Services
● Professional Fees
● Hospital-Inpatient Stay
● Outpatient Diagnostic and Therapeutic Services.
Give at least 3 Preventive Services.
Annual Physical
Wellness Exam
Well-Baby
Contraceptives
Vaccines/Immunizations
What tool do you use when checking if the member is enrolled in Medicaid?
DMEVS