Legislation
Where are the regulatory requirements and mandates 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 benefit plan exclusions.
What is Doc360 (ibagg) and PASS
What is the most important information you need to know before starting to prep a case?
What is the effective dates of eligibility.
Which platform do we use starting our benefit review in HSR?
What is big notification, little notification
What funding arrangements provides full financial protection for our customers?
What is Fully Insurred
This is the first place we look for review of service codes?
What is EPAL or PNL
This tool is used to check benefit plan language for large to medium size accounts.
What is Doc360
What is the best identifier to use when referring to a specific case?
What is the SRN Service Reference Number
What number do you use 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
We go to this site to find if a code has Claim Processing Instructions (CPI)?
What is (KL) Knowledge Library
This tool is used to check benefit plan language for policies number 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 is the provider identifier list.
Which tab in HSR would 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 the URUM
This is the 3rd stop for code review. Before we administratively approve a service code we must stop here.
What is Benefit Plan Exclusion JA
Emails about policy plan language can be found on this site?
What is CBCG
This directs you to where to find specific plan language in a case?
What is the Policy number.
This tab is 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 Jurdication.
What is the Applicability UR decision tree
The service code is listed on the PNL as a general paycode in blue. If it is an ASO code, I must go here before I approve it.
What is the ASO General Excluded Accounts List.
The generic plan language for SPD's is called?
What is E&I Benefit Template
This determines if a member has in or out of network benefits for review?
What is the Product Description Summary JA
You can check this tab to make sure all of your compliance requirements are marked as complete?
What is tab 5 Decisions tab.