Claims
The two types of claim forms that providers and facilities bill with.
What are CMS-1500s and UB-04s
This routine financial process is used to issue payments to providers for approved claims.
What is a check run?
This is what should be checked for if a member is calling to verify if they have been approved to see a specialist.
What is an authorization?
This term describes the fixed dollar amount a member must pay before the health plan begins paying for covered services.
What is a deductible?
This is the designation used to identify a contracted vendor in Epic
What is A1?
This code set standardizes diagnoses across all payers and is required on nearly all medical claims.
What is ICD-10?
When a provider is paid in error and we seek the funds back, this process is initiated.
What is a refund request and/or recoupment?
This is what is sued to route a complex claim question to the claims department.
What is a CRM?
This is the program that providers can request access to in order to look up the status of a claim, among other things.
What is PHSO Link?
Provider Dispute Resolution (PDR)
What a provider submits when they don't agree with the a claim determination
This is the IRS form that we use to confirm a provider's TIN.
What is a W-9?
This is what DOFR stands for.
What is Division of Financial Responsiblity?
This is the method that health plans use to deduct money from us for claims paid on our behalf, retro terminations, etc?
What is a cap deduction?
Optum CES
What is the software that we use to check for incorrect coding?
This is the electronic version of a Provider Remittance.
What is an 837?
This is the percentage of inbound calls where the customer hangs up before reaching a live agent.
What is the abandonment rate?
This date represents the first day a member is entitled to receive covered services from UCSD or a UCSD affiliate?
What is the PCP effective date for UCSD (or the affiliate)?
When a provider joins the network, this document outlines their reimbursement terms and contractual obligations.
What is a provider contract?
AB-3275
What is the assembly bill/legislation that changed the time frames and interest rules under which all commercial claims must be processed.
This is a program that allows us to recover the cost of some injectables that we pay.
What is the Richman Bill?
After calling managed care customer service, this is who should press Option 2 after the initial greeting starts to play.
Who is a patient/member?
A member appearing inactive in the system may require this step to verify whether eligibility records are outdated or pending.
What is checking the plan eligibility portal/website?
This term refers to the maximum amount that we will reimburse a provider for a covered service.
What is the contracted rate?