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?
These two sites can be used to do a quick check of the allowed number of therapy visits.
What are IBAAG and PASS?
The most important information you need to know before starting to prep a case.
What is the effective dates of eligibility?
The platform we use when starting our benefit review in HSR.
What is Notification (big notification, little notification)?
The funding arrangement which provides full financial protection for our customers.
What is Fully Insured?
The first place we look for when reviewing service codes.
What is EPAL or PNL?
The tool used to first look for benefit plan language for medium to large sized accounts.
What is Doc360?
The best identifier to use when referring to a specific case.
What is the SRN Service Reference Number?
The number you use to search for family members on the same policy.
What is the member's ID number?
The funding arrangement that frequently covers teachers, state and city government workers.
What is NEASO?
The site to look to see if a code has Claim Processing Instructions (CPI).
What is (KL) Knowledge Library?
The tool used to check first for benefit plan language for policies number which contain a letter in them.
What is PRIME?
We 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 History tab?
You go here to find specific state requirements including TAT.
What is CRR (UCS Regulatory Adherence & Accreditation) site?
The 3rd step for code review. Before we administratively approve a service code we must stop here.
What is the Paycode Exception Job Aid?
Emails about policy plan language clarification can be found on this site.
What is CBCG?
The piece of information you use to look up the specific benefit plan policy.
What is the Policy number?
The tab where you can send approval faxes to providers and request clinicals.
What is tab 11 Review Request?
When you have a difference in SOI and SOR you use this tool to determine the state of Jurisdiction.
What is the Applicability UR decision tree or Applicability UR?
The service code is listed on the PNL as Administrative Approvable. If it is an ASO policy, I must go here before I approve it.
What is the ASO General Excluded Accounts List?
The template for generic plan language for SPD's.
What is E&I Benefit Template?
The Job Aid that tells us plan information such as whether the member has INN benefits only or INN and OON benefits.
What is the Product Summary Description JA?
Check this tab to make sure all of your compliance requirements are marked as complete.
What is tab 5 Decisions tab?