KMS
What is PHP01?
The two places online you can find the Prior Authorization Request Form.
What is Provlink and the PHP External Website.
What is the benefit for all the ASO other groups (except for Benchmade knode, Riverpoint and Marathon coach) for tubal ligation in network with a contraceptive dx?
What is "Covered in Full"?
Did this claim deny 192285021700 ?
What is: No, processed OON due to referral violation
When does a PEBB choice member need a referral to see an alt care provider.
What is when the provider has the provchoice network line in Facets
What is the hearing aid benefit for mbr # 100681009-00 Lind Muir?
What is:
Any Willing Provider (no IN/OON), 250 DED 15 coins 1900 OOPM
Limit: One per ear every 3 calendar years.
The reason why CL 170720035000 denied.
What is: YEP - Other Insurance. Please resubmit primary EOP?
What has to happen after we received a retro referral on file after a claim has processed out-of-network due to referral violation.
What is "the claim needs to be reprocessed with the retro referral attached"?
The in network benefit quote for HCPC code L3000 for MBR ID 100756668-00 and what location code is this covered at?
What is:
No DED 20 COINS 1200 OOPM
limited to 200 per cyr
Covered at all locations
The reason why CL 193435463000 denied and did it deny to the member or the provider
What is: CVW Coverage Exclusion
Denied to member
True or false: No referral is required for TMJ Splint Services.
What is TRUE?
The provider relations rep responsible for Crook County.
Who is Robin Solomon?
The steps you take to get to the medical policies on Provlink.
The maternity in-network benefit quote for MBR ID 100547284-00 for a baby girl.
What are:
Prenatal Visits: CIF, DED waived
Delivery/Postnatal Visits: ded wvd 250 cp 2350 oopm
Inpatient Hospital/Facility Services: 350 ded 20 coins2350 oopm
Routine Newborn Nursery Care: ded wvd 20 coins 2350 OOPM
The reason why CL 183255484300 denied and what would we tell the provider.
What is: z60 Not a primary Diagnosis Code
The dx cannot be used in the primary position and would need rebill with a correct dx in the primary position
Why was the PA denied for mbr # 100690218-03 Alendara Ruiz Anderson PA# P195815.
What would we tell the member
What is: Does not meet medical criteria
We would tell the member to contact their provider to discuss next steps
The Timely Filing Requirement for an initial submission on a claim.
*BONUS: What is the timely filing requirement for a corrected claim for Oregon-based plans?
What is 12 months from the DOS?
*BONUS: What is 18 months from the processed date?
The steps you take to get to the payment policies on Provlink.
What are: Home page - Resources - Policies - Coding
The acupuncture benefit quote for MBR ID 100106177-00 to see Jeremy Jacks and do they need a referral
What is:
Acupuncture-250 ded 10 cp that does not apply tot he oopm
1000 per cyr combined with acu/chiro/MT
Alt Care OV-250 ded 10 copay that does not apply to the OOPM
Xrays/Labs-ded wvd CIF
Outpatient Rehab-DED $250 , 10 CP 1500 OOPM with a combined limit between PT/OT/ST of 60 visits PCY
No referral req
The reason why CL 193435180900 denied and it is denying to the member or the provider
What is: BWH Age/Gender Not valid for Diag/Proc
denying to the provider
How many office visits were used and what are the DOS it was used for referral # 1917209900 used for mbr # 100694370-00 Cheryl Boedigheimer .
What is 3 OV used and the DOS were 8/2/2019, 9/13/2019 and 10/11/2019