Claims
In what status must a claim be in to provide member and/or provider responsibility?
02 status.
True or False:
We only need to click note one affected claim in our task.
True.
What all benefits should you quote if a member is asking about maternity?
Maternity
Radiology/Lab
Preventive (Breast pump)
Professional (Other professional services)
Newborn Care
True or False:
Preauthorization is not required for chiropractic, acupuncture, or massage services, unless otherwise indicated on the group page/benefit booklet.
True.
Tasks pended back to the CSP are to be updated when?
Within 48 hours or 2 calendar days of receipt.
What is the standard processing time for new claims?
30 days from the date of receipt.
True or False:
We can provide OPL's email address and/or fax number to the callers.
True. But not the phone number.
A caller reaches a CSP and indicates the caller has a question but the call/chat drops before the CSP can capture any information from the contact. The Member ID number has displayed in SDS / Live Help screen. Is a task required?
No, no information has not been exchanged.
Who do you email for Carelon and eviCore issues?
Gwen Smith.
See KMT 21215 for scenarios.
How do you put multiple diagnosis codes in BQT when you only have one CPT code?
Put them all in the first box, separating them by commas.
In what claim status are amounts applied to the deductible included in the accumulators?
01 status.
True or False:
If there is OPL and a task needs to be pended, the Subject must be Claims and the Category must be Accident.
True. If the subject and category are not filled out correctly, the task will be returned to the CSP who originated the task.
Caller reaches the general Customer Service queue but has a question regarding a topic handled by a dedicated queue. CSP advises the call is handled by a dedicated team and transfers the call. Is a task required?
No, no information has been exchanged.
If a member requests all documentation related to their preauthorization, what do you do?
Follow the steps on KMT 29935. Email the template to ClinicalServiceIntakeAllDocRequests@regence.com.
True or False:
You should email ASO membership for issues with the State of Idaho group members.
False. State of Idaho is technically a fully insured group. We should email SOID.Membership@regence.com.
If a member asks for a Payer ID to provide to their doctor, what should you give them?
Tell them that payer IDs are specific to the provider and their clearinghouse, so we have nothing to provide.
KMT 15685.
When connecting your caller to OPL and the hold time is longer than 3 minutes, what should you do?
Obtain all applicable information and pend the task to OPL. Advise the caller that the other department might reach out to them.
We are currently working with OPL to allow cold transfers for holds longer than 3 minutes. Stay tuned.
If necessary, you can still hold longer. But do it sparingly.
True or False:
It is required to quote "of the allowed amount" and "balance of billed charges."
False. Our legal department has determined that this should only be considered a best practice, not an MTM requirement.
Where can you locate preauthorization timeframes?
Regence/Asuris/BridgeSpan provider websites.
See KMT 29996 for steps.
What KMT page can you use to check backlogs and status of other departments?
30277. Workflow Status Reports.
What is the difference between the Finalized Date and the Processed Date when looking at a claim in SDS?
The Finalized Date is when the claim finished processing. The Processed Date is the date that the check/payment was requested by the system AND is the date used to determine timely filing for adjustments and appeal timelines.
If the Date of Injury is 05/21/2024 in the OPL tab, but the member gives 06/01/2024 as the Date of Accident Injury Illness Onset Date, what should you do?
A. Accept the 06/01/2024 date and release OPL.
B. Warm transfer the caller to OPL because they gave a later date.
C. Ask probing questions for what happened on or before 05/21/2024.
Answer: C.
True or False:
If the benefit in question is subject to a maximum or limitation, it is a requirement to quote the maximum/limitation and the amount used thus far, even if it is 0.
True.
If a member has a current authorization on file with Carelon and wants to use a different provider, who can call Carelon to request this update?
The current provider
The new provider
The ordering physician
CSP
Where should claims for independent clinical laboratories be sent?
The state/service area that the referring provider is located in. Always double check the network status of the lab with that specific state/service area.