Feeling lucky?
This happens to the claim when a Choice/Connect member is seen in Arizona by a dermatologist.
*Be specific*
What is that the claim processes out-of-network?
An individual member is leaving for vacation next week. She's going to run out of her prescription while she is gone. This is what you'd do...
What is transfer to pharmacy for a vacation override?
Whether or not there is a limit to how many mastectomy bras a group or individual member can have in a calendar year.
What is no limit?
Whether or not bariatric surgery is covered for an individual member.
What is no?
Place of service 25 indicates this.
What is a birthing center?
The three places that a prior authorization form can be found.
Where are 1) KMS 2) PHP external website 3) Provlink?
The BIN and PCN # for an individual member.
What is BIN 600428 and PCN 06680000?
The explanation code CVX indicates this.
What is "Cover Exclusion, Member Resp"?
Modifier E1 indicates this.
What is upper left eyelid?
The amount of time prior to delivery that members can obtain a commercial grade breast pump through Providence Home Services.
What is 60 days?
This is the PR rep for Crook county.
Who is Robin Solomon?
Whether or not a MAST and RAST allergy testing require a prior authorization or not.
What is yes?
Hospital type of bill code 117 is for this.
What is Hospital - Inpatient - Replacement of prior claim?
Member is requesting a copy of their designated record set (DRS). This is the name of the form that has to be sent to the member, and also this is the amount the member has to pay to obtain their DRS.
What is the "Member Request for Access to a Designated Record Set" and what is $25?
Tonya is calling from Central Texas Imaging Center, 32nd Street in Austin, Texas, for MBR ID 100742153-00, Dave Baker. Dave is going in for an MRI. This is what you would tell the provider...
What is: $4000 DED, 20% coinsurance up to the $11000 OOPM? No PA required from AIM for FH providers.
MBR ID 113121847-00, Cynthia Porter, is going in for a colonoscopy and an endoscopy (Upper GI endoscopy). She is going to see Dr. Jeffrey Duman and have the procedures done at Providence Newberg Medical Center. These are her benefits...
What are:
Colonoscopy - CIF for mbrs 50+ w/ a referral on file
Referral 180250506 on file for provider Dr. Jeffrey Duman for 01/18/18-01/18/19
Endoscopy: CIF for both professional and facility fees after $7900 deductible is met (ACT applies - however there is no CP amount listed - CIF after deductible since deductible is the same as the OOP)
True or false: Home prothrombin time self-testing INR (INR Self Testing) is a covered benefit for individual members.
What is false?
Member Maggie Klein, ID # 113122058-01, is calling because she is traveling to England for vacation. She wants to know if she is covered while she is there if something happens, and if she needs to get some sort of notice or letter from Providence before she travels. This is what you'd tell her...
What is the following:
Plans with Out of Network benefits:
COVERED AT IN NET RATE FOR URGENT AND EMERGENT SERVICES
PREVENTIVE AND ALL OTHER SERVICES COVERED AT OON RATE
PAY UPFRONT AND SUBMIT FOR REIMBURSEMENT UPON RETURN. KEEP ALL ITEMIZED BILLS/RECEIPTS FOR SUBMISSION
PHP DOES NOT COVER COST OF TRAVEL BACK TO STATES
CLAIM REIMBURSEMENT FORM AVAILABLE ONLINE
No letter is generated prior to member traveling. Member will simply pay for services upfront and submit a member reimbursement form to PHP to be reimbursed for any amount payable per their benefits.
Using MBR ID 100129262-00, tell me what network that Kootenai Medical Center (Coeur D Alene, ID) is participating with and where a provider would mail their claim.
What is First Choice Health Network? And where is PO Box 2289 Seattle, WA 98111?
This is what Payment Policy 31.0 is regarding.
What is Modifier-25?
True or false: Visit limits duplicate if a member is double covered.
What is false? Visit limits do not duplicate. For example if a members primary plan has 30 visits for outpatient rehab and the secondary plan also has 30 visits, they only have a total of 30 visits per year.
Member Dale Stuzman, ID # 113337291-00 is calling to check if a valid referral is on file for Dr. Michael Krnacik. This is what you'd tell her...
What is yes? Referral 190090686 is for Dr. Michael Van Anrooy, but both providers have the same specialty (Orthopedic Surgery), practice at the same address and share the same TIN. Referral is valid for either provider.
Tiffany from Dr. Seth Stankus' office/TIN 911939739 (J Street) is calling to find out where she can mail and/or fax her claim to for MBR ID 113343236-00.
Where is FCHN - PO Box 2289 Seattle, WA 98111 and/or 206-268-6181?
What is yes? Transfer the call to PBH.
AKA: Electroconvulsive Therapy (ECT)
Whether or not shipping and handling charges are covered for medical equipment.
What is no?