Scenario
If a PA has a board cert. listed but you are unable to veriy it, what does the SOP advise you to do? This would only be applicable to an INI file.
What clues on a CC give you the indication that you need to hit the order data button.
View the historic status codes and if 101 is listed, then you need to hit the order data button.
Also, if you notice under the elements that nothing is listed.
Virtual providers get what waiver?
DEA and Hospital Privileges
Which team meber has been with UHC the longest?
Brian
You completed the initial outreach to obtain the provider’s hospital admitting privileges and PROMISE ID. The credentialing contact responded and provided a document containing privileged information; however, the document is in an unacceptable status for UHC. What is your next step?
- Make a 2nd outreach to advise the cred contact that the informiaotn they sent for hospital priv. does not meet critereia and give them the oppertunity to send you acceptable information.
DPMs- Council on Podiatric Medical Education
website: https://www.cpme.org/residencies/ResidenciesList.cfm?navItemNumber=2242#MI
Would a recred file have the order data button?
NO
101/order data button are only for INI files
Per the last all team meeting, what is NCC job?
to build and maintain a quality network of providers and orgs.
Who is the youngest team member?
Diamon
What is your responsibility if you are verify the OIG element and unknow source is listed?
If unknown source is listed you are requried to go and make the verificaiton and correct the source informaion in the source feild.
True or false: If a proivder hospital privilege category is restricted, you will 505 that file and deny for NO HOSPITAL PRIVILEGES OR PARTICIPATING ADMITTING ARRANGEMENTS?
False: Per the hospital priv catergory tab, you will 334 the file for reveiw.
Which section of the SOP directs you to hit the order data button?
Cred Decision Needed under step 8.
What is the difference between what the API does and what CVO delivers for a PSV?
API: A basic program. It’s checking the websites and produces returns. Your job is to make sure what the API delivered to you is valid data, not trash.
CVO (Credentialing Verification Organization): Somebody that is doing the same if not a similar job to what you do. An actual person pulled the provider from a website. Double check to make sure they pulled the correct information.
Which team member has a rabbit as a pet?
Kishie
A file you conducted outreach on yesterday is now showing a 152 code in NDB in addition to your 320. What is needed?
152 Indicates possibly delegated provider is showing in an active credentialing process under the NCC (requires review to verify if processing incorrectly).
You will need to reveiw to see if the delgated entiry was added to the provider on ITC. If yes, then you follow the delegated SOP.
True or False: If you are deny a file becasue you have not received the reply back for the current PLI, exception reason will be:
Excetpiona reason (general): Liability Insurance
Exception reason (speicific): NON-RESPONSIVE TO REQUEST FOR PROFESSIONAL LIABILITY INSURANCE
False: NON-RESPONSIVE TO REQUEST FOR PROFESSIONAL LIABILITY INSURANCE is only to be used for facility. You would deny for NO PROFESSIONAL LIABILITY INSURANCE.
Which state would never require the order data button to be hit?
For providers in Minnesota (MCC), do not click Order Data. The following comment will auto-populate in the General Comments of the CC:
Non-CAQH app needs to be pulled from the appropriate portal; No MPIN could be found for the Provider, please create the MPIN; System was unable to automate all addresses, please review and take the necessary steps to resolve.
If a provider opts out of Medicare, how do we handle the file?
Do not deny the whole file, split for Medicare.
Which advocate (s) lives in North Carolina?
Alfreda and Katrina
YOu are processing a recred. The provider name on your CC in SFL is Jane Renee Smith but NDB show Jane R. Johnson. How do we correct this.
We are not to update names for recred. The providers office would need to send in document to hpdemo to verify the name change.
If a provider has a sanaction for Illegal drug use or chemical substance use from 2010, what is your obilgations?
if no supporting explanation to accompany response, outreach to provider to verify answered correctly.
If answered correctly, with or without explanation, file requires review
Daily Double (Bounse Question): In Omega, what are you subcategory and detail when logging at the end of your shift?
Activity: Exception time
Subcategory: Admin
Detail: admin task
Your CC needs a Site Visit. You check the SharePoint and find there is one pending. What is your next step?
Answer: On the Site Visit request that is in process add a comment: Site Visit also needed for CC# / MPIN / TIN / Provider Name / your name. Once this SV is completed, please provide results.
Who fun fact from the Guess Who Game was: This team member lives in the Hoosier State-where basketball is a lifestyle and corn is basically a food group
Zanetta