Benefits
Rebecca has been seen twice for code G0402 but her second visit was denied although not in the same month. What is the reason?
**BONUS $500- what would be the appropriate code to use as subsequent?
Annual Wellness Visit is only covered once every 12 months
***BONUS Answer- G0439
Member Carol Jobe ID: H48483731 is currently in the Catastrophic stage, how much of her Troop did she actually spend?
$2315.50 (TrooP is the combination of member spend and any discounts)
OON network provider Nelson is resubmitting a claim with a recoupment date of 2/14/2021 on 7/16/2021, is he within timely filing guidelines?
No, he is allowed 3 mos. from the recoupment date
To authenticate a members identify- Name 2 pieces of information you should request
Member’s ID number, Member's name, Member’s DOB, Member's ZIP code, Member's group name, group number, or product type, Unique Member ID Number, Medicare ID#, Account Number
According to Availity Overview and FAQs- What is the 2-step authentication process for users to access their account?
AND
What is the ph# to contact Availity?
After logging in with their username and password, the user is prompted to enter a unique code, which they have received via text, voice call, or the Google Authenticator App. Every user is required to register for 2-step authentication and will be asked a series of questions uniquely created for each specific user.
Contact Availity Client Services (ACS) at 1-800- 282–4548
What benefit would code 90653 or Q2038 fall under and what are the benefits for plan H5216-238 (PPO)
Immunizations- once each flu season in the fall and winter, with additional flu shots if medically necessary; Benefits are no coinsurance INN or OON
Member Evelyn Banks ID: H74990340 has a prescription for metoprolol succinate, what would be the total cost and member pays amount for Preferred Retail Pharmacy? (30 day supply)
$702.50
Physician Ben is submitting a corrected claim after the timely filing period to remove a service he’d initially submitted, Is this allowed?
Corrections can be submitted after the timely filing period, but it must be corrections, not new charges
To provide information about an authorization, what 3 things can the provider give to receive sensitive information?
Date of service, rendering physician or hospital, Service provided
According to PN Escalation Process- What should a PN do if a lead is not available to assist with call requiring additional research?
Navigator will task the BSS team in Sugar for further research indicating item is escalated (2-4 business days depending on area).
If member Laura was eating at a restaurant, fell ill and was later diagnosed with E857 and E8842, what type of call might this turn into if not only benefits are needed?
Subrogation
Member Don Missildine ID: H72846972 has paid for 2 different mail orders- can you name 3 of the drugs he paid for?
VITAMIN D2; OMEPRAZOLE; ROSUVASTATIN; AMLODIPINE; LEVOTHYROXINE; FENOFIBRATE
INN physician Miranda has a contract exemption that allows him 15 mos. to submit a claim. She submitted a claim on 12/19/2022 for DOS 9/5/2021, is he within timely filing guidelines?
No, Miranda should’ve submitted by 12/5/2022
If a provider calls about a claim that has already paid or denied, what info should you request outside of provider authentication?
Dates of service/dates of fill (for pharmacy), Provider name (including treating physician, facility, or pharmacy name), Claim Number or RX Number
According to ‘Request to Change Provider Information’- what type of task should be created by the PN?
Provider Update
Jim has a diagnosis of 305.52 and the provider is looking for appropriate benefits for treatment, what would you quote for plan H5619-083 (HMO)?
Opioid treatment program services- $40 copay in specialists office, $100 copayment Outpatient Hospital; $55 copayment partial hospitalization
Member Carol Jobe ID: H48483731 Is member getting the BEST DEAL for drug Eliquis he receives through OMNICARE OF GOLDEN?
No, the best deal would be a 90-day supply
A home health claim with start date 2/7/2021 has been submitted on 10/22/2021- Is this considered timely if it is the latter date?
No, 120 days are allowed at the start of episode
If a provider is calling for multiple patients from multiple facilities- what must they provide?
TIN for each facility as well as authentication for each member individually
According to Authorization Approval- What team should a provider be warmed transferred should they have additional authorization questions?
Navigator reaches out to Right Care Team on Teams to request a warm call transfer. If the Right Care Team is available, Navigator will conference the Right Care team in to conduct a warm transfer. * if the Right Care Team is unavailable, Navigator creates a task to assign to the Right Care Team for follow up.
Lisa has HumanaChoice H5216-237 (PPO). Claim 12345 with service code S8930 has denial code of 0H* and the provider wants to know why. What information could you provide about the benefits of this service?
Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: For the purpose of this benefit, chronic low back pain is defined as:
• Lasting 12 weeks or longer;
• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); • not associated with surgery; and
• not associated with pregnancy
Member George Smith ID: H03803051 Will George make it to the next stage by December? (if he doesn’t get any additional drugs are prescribed)
No he has several tier 1-2 drugs with very lost costs. He still needs to spend $3,309.59
An original claim was processed on 7/18/2021-the provider wants to know if he can submit the additional information per our request on 12/9/2021, after Jan 2022- Is this allowed?
Yes; the information must be received within 45 days from the request
What information cannot be disclosed to a provider?
Any information pertaining to another provider and/or Any information regarding services not rendered by the provider requesting information
According to Grievance and Appeal Inquiry- What is the turn around time after a task is sent to BSS team and who should follow up with the provider?
48 hours; Provider Navigator reaches back out to the provider to provide the resolution, documents, and ends call.