Codes
Claims
Benefits
HIPAA
True/False
100
What mentor is needed to verify guidance on EX Codes?

EX Code Guide CCC Provider!

100

What system is always used FIRST to start a claim call?

CRM! 

CRM 1st, CI 2nd! 

100

What is the copay for DME?

$0 copay as long as member goes INN

100

Why do we have to follow HIPAA?

To protect patients and their confidentiality! 

100

We always verify a good callback number!

TRUE!

200

What description shows for EX Code 007?

Request for Medicare EOB

200

You are investigating a claim and see it has been pended. Do you communicate this to the provider? 

NO! Never tell the provider a claim has been pended! Inform the claim is still processing! 

200

How many visits per year is approved for Home Health?

36 nursing and/or home health visits per calander year! Make sure they are going INN as well!

200

What is an NPI?

National Provider Identifier specific to a provider! 

200

We ALWAYS aux meals for lunch in genesys!

FALSE! LOG OFF for lunch in genesys!

300

What mentor document is needed for EX Code 016?

Turnaround Time Expectations CCC Provider!

300

What mentor document is needed to check claim status? 

Claim Status Overview CCC Provider!

300

What are the base services covered for Opioid Treatment? 

Covered as medically necessary, includes 6 phase programs! 

300

If a member has NOT been authenticated, can we release the effective date of the plan? 

NO! 

300

We always cold transfer no matter what the call volume is!

FALSE! Depending on the call volume, your supervisor will put in your team chat if its warm or cold transfers! 

400

What do you advise the provider when seeing an EX Code 014?

Advise the caller that services are not covered when provided at no charge to the member. If needed, advise the caller to submit a corrected claim. DO NOT send to CRU as CRU cannot adjust the claim. 

400

Why do we use the RFI screen in CI?

RFI screen shows us referrals submitted from a member's PCP. 

We would first check CRM Auth/Ref tab. Remember, CRM 1st, CI 2nd!

400

What base services are excluded for telehealth visits? 

Physical, Occupational, Speech, and/or Hearing services! 

400

If a provider has NOT been authenticated, can we release contract information? 

NO!

400

We can clock out 10mins early because we clocked in 10mins early! 

FALSE! If my schedule was 9-5:30, I would not LOG OFF until 5:30

500

You are investigating a claim, you see 2 EX Codes for 2 different services. What is the description for each? 

016 & 017

016- Pend for pre-existing investigation 

017- Clarification of diagnosis code requested 

500

What is the control line to reach the MRI screen?

MRI,Member ID

500

How many eyeglasses per year can children under 21 receive? 

2 eyeglasses per year! 

500

Besides verifying the tax id/npi, what else is needed when speaking to a provider? 

Callers name, callback number, and facilities name! 

500

Medicaid members can see any provider they want!

FALSE! Only INN providers UNLESS there is an approved waiver on file allowing them to go OON!