Provider
These are the three Provider Network Statuses.
What are Non-Par, Par, and PPO?
(alternate: Non-Participating, Participating, Preferred)
These are our three offered Benefit Plans.
What are Standard Option, Basic Option, and FEP Blue Focus?
These are the Four P's.
What are Pre-Certification, Prior Approval, Pre-Determination, Post Service Review?
Deferrals that have plan-specific processing steps that required analyst intervention are issued by...?
Who is the Local Plan?
This RPI is used when manually pricing a claim.
What is RPI N?
These four states are within the service area of our Plan.
What are Washington, Utah, Oregon, and Idaho?
What is Retrieval?
What are Inpatient Facility Stays?
To bypass pre-deferrals that re-defer after resolution, the edit must be keyed into this field.
What is the Route Destination?
This guideline will help you determine the correct RPI for your claim.
What is Remote Pricing Indicator in the One Note?
These two specific laboratory providers have special processing instructions.
What are Labcorp and ARUP?
This section lists other insurance data for the members on the policy.
What is the OPL Roster?
This registrar name means that the authorization is for preventative services.
What is MMTUSER?
This is the reason it is important to review the claim level comments for an "ADJ 837" comment.
What are $100 for non-Medicare, and $50 for Medicare?
This Direction of Pay is used alongside the Dummy PRPR numbers.
What is Responsible Party?
These are the three matching criteria when trying to match a patient to a member.
This must be populated on the claim any time services have gone through applicable medical review.
What is the Medical Review Indicator?
This is the best way to determine which Timely Filing guideline to review.
What is the deferral hit: B12 = Adjustment, B14 = Original.
The Maximum Allowable Charge (MAC) is specific to this claim type.
What is Dental?
A valid PRPR contains these four matching criteria.
What are the Tax-ID, Provider Name, Date of Service, Pay-To Address?
These are the three locations where Nicknames can be verified.
What are the Member Summary, Misc Info, and Previous Names?
These fields must be populated when processing deferrals related to Prior Approval.
This is the type of weather Joanna prefers.
What is cold weather?
These items must be tracked in your deferral task comments when manually pricing a claim.
What are: the line that required pricing and the allowed amount for that line?