Insurance Verification
True or False
Traditional Medicare and a Medicare Advantage Plan can both be active on the patient's chart
False.
True or False
The patient's name should match what is on the insurance even if it does not match the face sheet.
True.
True or False
All authorization requests require all wound photos and encounter notes to be submitted with the request.
True.
True or False
Claims should be assigned to the provider after completing.
False!!
Where would you go to find if a specific specialty code is covered or not?
Specialty Billing Cheat Sheet
Can VA be billed along with another payer?
NO
The patient has the choice if they want to use their VA coverage or coverage from another payer.
Does it matter if the address is not validated?
Yes.
If it is not, this creates errors for billing statements.
True or False
We can submit retro authorizations to payers that do not accept retro requests.
FALSE.
Which 2 dashboard queues only require 6 items to be worked?
Rejections and Denials.
True or False:
MAP plans cover Hospice Care
FALSE
True or False
If a procedure code is not covered by the payer, we can not send a request to the authorization team to obtain approval.
TRUE
The payer address does not need to match what is on the insurance portal/card if the payer name matches.
False
The address needs to match UNLESS it specifies to bill to the local payer.
True or False
Authorization status should be followed up on and documented daily
TRUE
Yes or No
If a claim is assigned to me and I was not the one who made the error, it is not my responsibility to work it.
False.
Everyone is being assigned claims to work based on facility assignments and current workloads.
Which 5 payers ALWAYS require authorizations?
Blue Advantage
VA
American Health Advantage
Lagniappe Advantage
Wellcare
BONUS +100 pts: LHCC after 12 visits
Yes or No
You're verifying medicaid and the plan is inactive; however, the patient has QMB coverage. Does this need to be added to the chart? Please explain your answer.
Yes.
What steps are taken if a nursing home has patient has VA insurance but the facility has requested to be billed for their services?
Change the patient's insurance to "Self-Pay" and ad the facility as the guarantor.
True or false
If I am working in the pre-sub queue and the auth is still in pending status, I should assign it to patient access management.
False.
Do not reassign claims to management until the approval is received and claim is ready to be resubmitted.
Which dashboard queue requires ALL items to be completed?
Pre-Submission
Can there be both medicare managed care AND medicaid managed care plans active on the chart?
No.
If a provider is OON with a payer and the patient does not have OON benefits, what steps should be taken and who should be notified?
Notify management, after we confirm, you should then make the MOS or NH RCC or provider aware, and we will notify our credentialing department. Document all steps taken on the chart.
What steps should be taken when a patient treated at either an inpatient or outpatient (HBO) facility does not have traditional Medicare (MCR) or Medicaid (MCD) coverage?
Authorization approval must be obtained from facility and approval added to chart. If it is pending, action must be sent to auth bucket.
What steps should be taken if an authorization has been denied?
1. Schedule Peer To Peer
2. If deadline has passed, file an appeal.
If a claim is denied due to incorrect payer and the primary payer has been updated, what department should the claim be transferred to?
Coding
Claim Action: Transferred
Result Code: Transferred to Coding
If the patient's primary payer is something our company is NOT credentialed with but the patient has medicaid, do we just remove the primary payer and bill to medicaid?
No.
Medicaid will not cover any service not covered by the primary payer.