Eligibility
What is eligibility?
Being eligible for something means you meet all necessary qualifications
What is a claim?
Request for payment
What is an appeal?
What is a prior auth?
Requests for pre approvals obtained prior to a service being performed
WHAT DOES A FEE SCHEDULE TELL YOU?
THE PROVIDERS CONTRACTED RATE
What is a Deductible?
The amount patient pays before insurance starts paying
EOB stands for ?
EXPLINATION OF BENEFITS
What needs to be done if member calls for appeals in CSM?
Collect all valuable information, Then transfer to MMS
What info is needed for a prior auth
CPT code, diagnosis, provider info
WHAT IS A REMIT?
AN EXPLANATION OF PAYMENT TO THE PROVIDER (KM1222177)
What the difference between Copay and Coinsurance?
Copay is the fixed amount (dollar amount) a patient pays While Coinsurance is the percentage.
Why do providers use a ADA form?
To document services provided to member and submit those services to UNITEDHEALTH for reimbursement.
Why should a member follow up with an appeal?
to be sure we received it and its getting processed
WHY DO PROVIDERS CALL TO CHECK IF THEY ARE INN AND CHECK THE FEE SCHEDULE?
TO BE SURE MEMBER HAS COVERAGE & CHECK COST
WHAT IS A BENEFIT FAX BACK?
WRITTEN BENEFIT VERIFICATION
What is the difference between INN/ONN Provider
INN= Participating or contracted ONN= Non Participating or Not contracted
Where do you find the information needed to submit a follow up?
the claim
WHO CAN FILE AN APPEAL?
MEMBERS AND PROVIDERS
WHEN YOURE INPUTTING THE TO TO FROM DAY WHAT SHOULD YOU DO?
3 DAYS PRIOR TO THE DATE GIVEN AND 3 DAYS AFTER
WHAT IS THE FAX BACK DISCLAIMER IF IST BEING SENT A PUBLIC FAX?
WE CANNOT GURANTEE ALL INFORMATION STAYS PRIVATE
What is the disclaimer that should be given when doing a providers search for a member?
"This is the most current information we have we do suggest you contact the provider to be sure they are still participating and accepting your plan"
Corrected Claim vs Appeal
Fix error Dispute denial
CAN A APPEAL BE SUBMITTED MORE THAN ONCE? IF SO HOW MANY TIMES
YES, 3 TIMES
HOW MANY PRIOR AUTH TYPES ARE THERE AND WHAT ARE THEY ?
4, REGULAR AUTHS, RETRO AUTHS, P AUTHS, OR AUTHS
WHICH FEE SCHEDULES CAN BE FAXED OVER TO PROVIDER?
STANDARD