Validation
How can you identify a newborn claim?
*Date of Birth
Name (eg. "Baby Girl Smith")
Hold Codes (07, 09, 34, and/or 35 may generate on a claim)
If a claim is generating Hold Code 02 and are no authorizations/exceptions that apply to the claim, which hold code do you apply to deny the claim for No Auth?
Hold Code JN
What type of service does Hold Code SY generate on?
PT Services
SY = [Pay PT Services Once Per Claim]
What does COB mean?
Coordination of Benefits:
The member has another insurance carrier, other than HealthFirst.
(We work Medicaid claims and Medicaid is always the payer of last resort.)
True or False:
1407 is a PWP/HARP Value Code
FALSE:
1407 is not listed as a rate code in the State Rate Coding Taxonomy Grid
In the event there is a complete mismatch on member info, what do you need to do before denying with Hold Code CA?
Reach out to HelpDesk for confirmation to deny with Hold Code CA [Invalid CIN# FR MEMBER'S NAME]
What are two common types of Global Authorizations?
Inpatient authorizations and Surgery authorizations are two common global authorizations, which can be applied to all claims for services billed in conjunction with the inpatient stay or surgical procedure
True or False:
If BV or 42 generates on a line, but the line has a system-applied denial code, pricing is not required; you can V&E the BV/42.
FALSE
If BV or 42 generates on a line, it should still be addressed, even if the line is going to deny.
We must address all open hold codes, and any lines with your username on it is your responsibility.
True or False:
A red EDI claim will never have an EOP attached.
TRUE:
EDI claims (red/white claim forms in Macess) will never have an Explanation of Benefits attached. We will only see an EOP attached to a black/white paper claim
When would you apply Hold Code EZ to a claim?
Which delegated vendor handles authorizations for pain management?
OrthoNet
Pathology claims can be billed (up to) ___ days after a surgical procedure.
Pathology claims can be billed up to 14 days after a surgical procedure.
Which day(s) should we pend claims with unverified D0 and all Source fee IDs on every line?
Tuesdays
Check Run occurs on Tuesdays. We do not want to leave any Source claims in R status with $0 To Pay on Tuesdays.
On a COB claim, which Hold Code do you apply to indicate the maximum has already been paid by other insurance carrier?
Hold Code DF [Maximum Paid by Other Carrier]
What does Hold Code QY mean?
QY = Review Claim With Attachment
QY indicates there is additional documentation attached to the claim image (such as an EOP, Consent Form, Invoice, etc).
CL1034 - In the gray box
ME1014 - Under Enrollment
Name 3 places you could find a valid Authorization Numbers
Authorization Dashboard, Pega, EviCore, MHS CL1011, Claim Image (CL1038/CL1035)
Name 3 Northwell p-orgs
1X, 1Y, 11,2F, 2H, 24, 27, 32, 33, 34 71, 72, 73, 75
True or False:
If HealthFirst is paying secondary on a claim, the authorization requirement should be waived.
TRUE
The primary payer is responsible for obtaining authorization. If primary payer has paid for the service, we will trust the service was medically necessary and will pay secondary.
What is the PAS code for CPT 45378?
18
D3018A
Hold Code T9 means the service is only covered when billed with an asthma diagnosis.
If none of the asthma diagnoses listed in the Validation Manual are on the claim line, which hold code do you apply to deny the line?
Name 2 services that require an exact service code/CPT code match (i.e. upcoding/downcoding does NOT apply).
Skilled Nursing Facility, Home Health, DME
For Bonus Points:
Name 2 Home Health Benefit IDs
Name 3 Source Fee IDs
HES, GHL, HSC, GHV, GHY, GHK, GHD, GHR, GHT, GHJ, GHX, GHF
ME1013 displays the member's Other Insurance carriers. Which priority code indicates the other carrier is Primary?
Priority Code: 1
True or False:
There is NO LIMIT to the number of payable PAS codes.
TRUE
Each separate PAS code will added to the claim.
If two CPT codes share the same PAS code, the PAS code will only be added once.