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 benefit plan exclusions.
What are IBAAG and PASS?
This is the first piece of information you need to find before starting to prep a case.
What are the effective dates of eligibility?
Which platform do we use starting our benefit review in HSR?
What is the NOTIFICATION platform? (Big Notification, Little Notification)
This funding arrangement(s) provides full financial protection for our customers.
What is Fully Insured?
This is the first place we look in reviewing 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?
The best identifier to use when referring to a specific case?
What is the SRN (Service Reference Number)?
This is the number 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 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?
This is the tab in HSR where you would find referrals made by the PCP to other physicians for services.
What is tab 13 or the History tab?
You go to this tool in KL to find specific state requirements including TAT.
What is that state's URUM grid?
This is the 3rd stop for code review. Before we administratively approve a service code we must stop here.
What is Pay Code Exception JA?
Emails about policy plan language can be found on this site.
What is CBCG?
This helps you with knowing what to document in your case prep from the Benefit Plan language.
What is the Benefit Language Requirements JA?
This tab is where you can send approval faxes to providers and request clinicals.
What is tab 11 or the Review Request tab?
When you have a difference in what the SOI and SOR tell you to use, you use this tool to determine the (SOJ) State of Jurisdiction.
What is the Applicability UR decision tree?
The service code is listed on the PNL as an Administrative Approval code, however, the section notes I must look here for further information on ASO accounts.
What is the ASO General Excluded Accounts List?
This is the document for generic plan language for SPD's.
What is E&I Benefit Template?
This shows you if a member has INN and OON benefits or just INN benefits for reviewing a case.
What is the Plan Description Summary JA?
You can check this tab to make sure all of your compliance requirements are marked as complete.
What is tab 5 or the Decisions tab?