Appeals
What is the TAT for an expedited appeal?
Expedited Appeals – 72 hours.
What is the VDN for claims Heldesk?
26040
Does a PPO plan require a referral to see a specialist?
No
If a call is not CTI Validated, what information do you need from the caller to fully validate the account?
ID#, Name, DOB
What tab should you click to determine who the members Plan Sponsor is?
Policy Info Tab
Who can file an appeal?
The member, the member’s appointed representative, or Physician.
Via Task Team
What are the 2 type of fitness benefits?
SilverSneakers
Fitness Reimbursement
Can you provide the members MBI# to them?
Not under any circumstances.
Do we send out new ID cards every year?
No, only if there is a change to the plan that would effect the ID card.
How long does a member have to file an appeal?
60/65-day timeframe
What is the TAT for a rework?
Standard Turn Around Time (TAT) for rework is 2-5 business days
What benefit does an MRI fall under?
Complex Imaging
Service Center Info
PSPP
Back of ID Card
What is the TAT for reconsideration on a post service appeal at Level 1?
Standard Post-Service Appeals - 30 days
What is timely filing for a claim?
*Par Provider is 120 days
*Non Par Provider is 365 days
*Members have 365 days to file a claim for reimbursement.
If an ambulance is called on behalf of a Member but they are not transported, is it covered?
No. If the Member is not transported, it is not covered.
Can we make an outbound call to the member to get verbal auth?
No. The member has to already be on the line when we first get the call.
What is the TAT on a KTC task?
3-5 business Days
If a member is being discharged from a SNF with a NOMNC & wishes to extend their stay, who files the appeal?
The QIO for the state where the facility is located.
Name 3 ways a Member can submit for a reimbursement claim.
*Submit online on the Member website
*Mail reimbursement form & receipts to address on the back of the ID card
*Fax to 866-474-4040
Which tabs should we always check when quoting benefits to Members? (There are 2)
Accumulators & OON benefits.
What is considered confidential information?
We consider all member-identifiable medical or claim information confidential.
How do we update a members email address?
KA: 4245
Follow KA precisely & send to task team.