Legislation
Where the regulatory requirements and mandates are located
What is KL Knowledge Library?
Decision made by a CAC when the benefit plan indicates coverage for services are pay codes.
What is Administrative Approval?
The two sites which can be used to do a quick check for benefit plan exclusions
What are IBAAG and PASS?
This is the first thing you should check when screening a case
What are the effective dates of eligibility?
The platform we use when starting our Benefit Review in HSR
What is Notification?
The funding arrangement that provides full financial protection for our customers
What is Fully Insured?
The first place we look for when we begin our review of service codes
What is EPAL or PNL?
This tool is used to look for benefit plans for large to medium size accounts.
What is Doc360?
The best identifier to use when referring to a specific case
What is the Service Reference Number (SRN)?
The number used to search for family members on the same policy
What is the member's ID number?
This plan frequently covers teachers, state and city government workers.
What is NEASO?
The name of the tool used to find if a code has Claim Processing Instructions (CPI)
What is Knowledge Library (KL)?
This tool is used to look for benefit plans for policy numbers which contain a letter in them
What is PRIME?
You have to make sure these are set up correctly in a case so Medical Claims pays everyone correctly
What are the Provider Roles?
The tab in HSR where you find referrals made by the PCP to other physicians for services
What is tab 13, the History tab?
Where you find specific state requirements including TAT.
What is CRR or UCS Regulatory Adherence & Accreditation?
The 3rd step for code review. Before we Administratively Approve a service code we must look here.
What is the Paycode Exception JA?
The site where emails about policy plan language clarification can be found
What is CBCG?
This directs you to where to find specific Group/Policy plans
What is the Policy number?
This is the tab where you can send approval faxes to providers and request clinicals
What is tab 11 Review Request?
The name of the tool used to determine the State of Jurisdiction when you have a difference in SOI and SOR.
What is the Applicability UR decision tree?
When the service code is listed on the PNL as a general paycode in blue, for an ASO Group/Policy, we must look here before Administratively Approving the code
What is the ASO General Excluded Accounts List?
The name of the generic plan which has language for SPD's and can be used as a last resort when policy language cannot be found
What is E&I Benefit Template?
This Job Aid helps the reviewer determine if a member has in or out of network benefits
What is the Product Description Summary JA?
The tab you check to make sure all of your compliance requirements are marked as complete
What is tab 5 Decisions tab?