Prior Authorizations!
Q: Does HCPCS code E0601 require a PA?
A: Yes ; PA required for initial rental and a second PA required at 90 days to convert to purchase
Q: If a member is double covered by PHP, do their physical therapy visits double?
Q:Where does provider fax clinical edit inquiry form for denial code z58
A: 503-574-8609
Can my naturopath provide my Annual Gyn exam? (Non-grandfathered plan)
A: Yes
Find me the EDI payer ID table (where is it in KMS?
A:Topic: Claims or EDI eligibility
References
Q: Where do providers submit prior authorization for High tech Imaging?
A: AIM
Name four pieces of information that needs to be sent to COB team
CALLER (Include title/phone number): CARRIER (Include name/phone number): NAME/DOB OF SUBSCRIBER AND COVERED FAMILY MBRS: MBR ID: GROUP NUMBER: TYPE OF PLAN: TYPE OF COVERAGE: EFF DATE: TERMED DATE (If applicable
Q: What will the provider need to do if they disagree with denial code p08?
A: Provider must re-bill with corrected modifier
Member ID: 10095452000 I want to see an Acup; what am I covered for(Provider is non par)
A: Ov to alt care ded wvd 30% coin 2000 oopmax
Acup: Ded wvd 25 Cp $1500 max cyr bene combined with chiro
PT 500 ded 30% coin 2000 oopmax 60 visits pcyr ot/st/p
I have already met my OOPMAX If I go from on PHP group to another within PHP will my deductible and oopmax still be met? (Hint: make sure you are under fully small or large LOB in KMS)
A: No
Q: "Hi, we have a patient in the ER and they need a CT scan. Should we get PA for this?"
A: No
Is a pa required for an MRI if PHP is secondary?
If PHP is the secondary insurance, no PA is required as long as the provider follows the primary carrier's rules and the primary carrier allowed the service.
Q: What is the denial description for denial code z79
A: Cosmetic procedure
Claim 120513793300 Why did you not pay anything on this claim?
A: Chiro/Acup is not a covered benefit
I am on a choice plan. I am going to see a sleep medicine specialist just to get a sleep study. Do I need to get a referral for the sleep study? Where in KMS did you find this?
A: No referral required for sleep study; KMS topic: Referrals under FAQ
Q:Does procedure code 29870 require a PA?
A: No ; Code use to require PA but no longer does
Q: I am the subscriber on two group plans. How do I know which one is primary and which is secondary?
A: Which ever one has covered the member for the longer period of time
Q: what payment policy would you refer provider to for denial code z46 if they need more information?
A: Payment Policy 12.0
Claim 163013286901 What type of service are for the codes that the provider billed? What benefit do they apply to?
A: Modalities; OP rehab
"I am a provider. PHP is requesting a refund. I need you to auto recoup this" How do you do this?
A: Send a CSI to OFT with Subject "CxClaim Info" and Category "Refund/OPR Info." Use standard claims formatting and include DOS and claim number.
Q: "I'm calling from St. Davids Hospital in Austin, TX zip code 78705, does this patient need a PA for a Pet scan? Their card says their plan uses a signature network?"
A: No PA required. Hospital is par with PHCS/MP
Q: What is the Birthday Rule?
A:
1. Plan of parent whose birthday occurs first (earliest in the year). Or, the plan with the earliest effective date if the parents’ birthdays are the same.
2. Plan of parent whose birthday occurs second (latest in the year).
Q: "I am an in-network provider through multiplan and this claim has a clinical edit denial. Can I bill the member for this?"
A: yes
Note: If it is one of the denial codes that can be overridden, send it to the claims team!
Member ID: 11283072400 What is my chiro benefit? (Provider is inn) When does the benefit accumulators reset? Provider will not be doing x-rays
A: OV to alt care ded wvd 25 CP 3000 oopmax
Chiro Ded wvd 25 CP 500 Max Plan Year Benefit combined with acup
PT 500 ded 20 coin 3000 oopmax 30 visits per plan year
Member is on ADEC plan; March 1st plan renewal
Q: What does explanation code x72 mean?
A: Not Approved Technology