Claims
What's the claim review time frame?
What is the turn around time for PC review?
2 hours
Notes for claims should be notated where?
Claim Wizard
HSA: type of savings account that lets you set aside $ on a pre-tax basis to apy for qualified medical expenses. HSA funds roll over year to year & may earn interest. Employer & Mbr contribution
FSA: (Flexible spending arrangement) special account you put money into that you use to pay for certain out-of-pocket health care costs. Employers contribute to FSA. Tax free. Doesn't roll over to next year
HRA: employer-funded group health plans from which employees are reimbursed tax-free for qualified medical expenses up to a fixed dollar amount per year. Unused amounts may be rolled over to be used in subsequent years. The employer funds and owns the arrangement.
Highmark
What is the turn around time a CSC has to work pod faxes?
4 hours
Healthcare Bluebook, Teladoc, and Doctor on Demand are all...
Point Solutions
What is the 1st step if an approved authorization is sent to the incorrect fax number?
Confirm PHI was deleted/destroyed
What does SME stand for? (SME UMR phone number)
Subject Matter Expert
What auth status is used when building future maternity admission?
Approved Future OB Admit
Confirming and updating WHAT is important to help the PCG with outreaches?
Best contact number/ phone number
What are the items on the caller verification checklist? For provider calls & member calls
Member calls: Must verifiy one of the following: plan ID # SSN or last 4 of SSN authorization #
& Member name, Member DOB
Provider calls: must verify one of the following: mbr full name, plan ID #, SSN or last 3 of SSN, auth #
& mbr DOB or mbr zip code
What do you after you update COB, Accident Detail, Retro Authorization (approved)?
Raise claim issue for tracking purposes.
How many units do you put in the approved units box if you build an authorization & it turns red?
0
A provider calls in for benefits for a CT scan OP for our member. Provide the complete benefit based on this picture...
Auth, benefit, accumulations
What is the 2nd step of mitigation process, when PHI is released?
Confirm PHI was not disclosed with anyone else
This is the reason the claim processed towards the coinsurance is because....
The claim was billed with a medical dx code instead of a preventative dx code.
What are the 6 piece of info we need on TPA line for maternity auths?
Admit date, D/C date, Delivery date, Type of Delivery, Gender, Healthy or sick baby
When quoting benefits to a member, what are 3 probing questions we should be asking them?
Who is providing the service/Why they are having the service/What type of service are they having
What does HIPPA stand for? (100 bonus points if you can include the year it was signed into law)
Health Insurance Portability and Accountability Act of 1996