Medicare or Medicaid
A federal health insurance program primarily offered to people 65 and over
Medicare
Billed with standardized, 5-digit codes to indicate medical services
Outpatient claims are billed with CPT codes
Fill in the lyrics:
I don't have digital
I don't have diddly squat
It's not having what you want
It's wanting what you've got
___ ____ ___ ___ ____ ____
I'm gonna tell everyone to lighten up
"I'm gonna soak up the sun"
Soak Up the Sun by Sheryl Crow (2002)
Fill in the Blank:
Hakuna _________
and what does it mean?
Hakuna Matata: No worries, no problems
The Lion King
Toxic - Britney Spears (2003)
A member of the updating unit who says hello to everyone, and usually wears different colored Hawaiian shirts
Theo
What information can you find on Availity?
Pt Eligibility, Benefit details, Claim Status, Remittance information, Authorizations, Payment Information, Insurance Plan info
rlleabum
Umbrella
A joint federal and state program that provides free or low-cost health coverage to millions of Americans
Medicaid
Billed with a flat predetermined reimbursement amount for a period of time
Inpatient claims are billed with the DRG rate for the hospital stay
Fill in the lyrics:
Leanin' to the side, but you can't speed through
Two miles an hour so everybody sees you
There's an air of love and happiness
and this is the Fresh Prince's new definition of summer madness
_____ _______ _______ _________!
Time to sit back and unwind.
"Summer, Summer, Summertime"
Summertime by DJ Jazzy Jeff & the Fresh Prince (Will Smith) (1991)
List Winnie the Pooh's Hundred-Acre Wood friends?
Piglet, Tigger, Rabitt, Owl, Kanga, Little Roo, Eeyore, Christopher Robin
I Love Rock N' Roll - Joan Jett & the Blackhearts (1981)
A member of the Cash Posting unit who handles email requests for finding payments and moving payments
Leonor
True or False: Availity is the only provider portal that requires a verification code through another source (not email or text)
False
United Healthcare and Availity both require additional verification through an authenticator app
srecnsuen
Sunscreen
What is a value code and what coverage requiries it?
Medicaid requires value codes. A value code reports exact payment rates, billing locations, and coordination of benefits. (Ex. 24 is a rate code. 61 is a locator code). Value codes are paired with a dollar amount or alphanumeric string so the eMedNY processing system can accurately calculate reimbursement.
Claims are billed with treatments or procedures that a patient receives on a repeated, ongoing basis over a specified span of time
Outpatient Reoccurring Services (Unitized)
Standing on your mama's porch
You told me that you'd wait forever
Oh, and when you held me hand
I knew that it was now or never
Those we the best days of my life
Oh yeah
Back in the _____ ____ _____
Summer of '69 by Bryan Adams (1984)
Name that movie: A young woman wishes for a night off from her responsibilities. She receives help from a magical family member, attends a party, and meets the love of her life. However, she almost misses her curfew and flees from the party, leaving behind an important part of her wardrobe.
Cinderella
Beat It -Michael Jackson (1982)
Who is the coordinator of the Variance unit?
Melissa
True or False: The chat function is available for every payer listed on Availity
False
ldsaestcna
Sandcastle
Name the plans:
1. This covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
2. This plan covers all essential health benefits including dr visits, hospital, emergency care, prescription drugs, dental, and vision.
3. This covers medically necessary dr services, outpatient care, preventative services, and durable medical equipment
1. Medicare Part A
2. Medicaid HMO
3. Medicare Part B
What do you do when a coding review in needed?
Name the process for each
Inpatient - email Stacie Colonna for a possible review of the codes
Outpatient and Units - Request a review from Revenue Integrity using RIRV with the 1st line stating, "Coding Review Request"
See the curtains hangin' in the window
In the evening on a Friday night
A little light a-shinin' through the window
Lets me know everything's all right
_____ ______ makes me feel fine
Blowin through the jasmine in my mind
Summer Breeze by Seals and Crofts (1972)
What are the names of the proud spotted canine parents of 99 puppies?
Pongo and Perdita (101 Dalmatians)
Who is the administrator for Epaces and Connex access?
Taylor
How many insurance payers are available on Availity?
More than 2,700 payers are connected on Availity nationwide. This represents over 95% of all health plans in the U.S. We can see only 91 from the drop down lists
tnlaatic caneo
Atlantic Ocean
What are the guidelines for billing Medicare?
For billing Medicaid?
Medicare: Follow COB and MSP requirements, timely filing limit is 1 year from date of service, must follow CSM standards, must accept payments determined by the Medicare rate.
Medicaid: requires providers to have active state enrollment, a timely filing limit of 90 days from the date of service, providers may NOT balance bill patients, accept that Medicaid is the payer of last resort, and accept payments based on the Medicaid fee schedule.
How do we handle appeals for Medical Necessity, Experimental, and No Authorization?
Inpatient: review the account and vet the authorization. Reassign to Denials and Appeals if the account qualifies for referral, using RTDA
Outpatient: review the account and vet the authorization. Follow the RIRV process for possible escalation to Revenue Integrity
I can see you
Your brown skin shining in the sun
I see you walking real slow
Smiling at everyone
I can tell you my love for you will still be strong
After ____ ____ ____ ____, have gone
The Boys of Summer by Don Henley (1984)
Name all of the 7 dwarves from Snow White?
Doc, Happy, Grumpy, Bashful, Sleepy, Sneezy, Dopey
Who is the supervisor of Denials and Appeals?
Kathleen Linarello
List some of the major payers available on Availity
Aetna, Anthem BC, Carelon, Centivo, Fidelis, Healthfirst, Healthspring, Humana, Tricare, Wellcare, Wellpoint
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Shark Week