Good Luck!
What is the TAT for EOR via MAIL?
10 - 14 business days
mentor: Medical Turnaround Time Expectations - PCC
For OON provider, requesting to update their demographics. What should be our guidance?
On the Overview Tab, Step # 3
3. Is the provider out of network?
"If yes, advise the provider to submit all demographic updates as correspondence.
Refer to PCC Addresses Faxes and Telephone Number Listing. "
mentor: Provider Issues for PCCs
What is the passing rate for ATR?
5.00 %
What is the TAT for Claim Processing (initial and corrected claim) for Commercial Plans and MEDICARE Advantage Plans?
Commercial: 20–30 calendar days
Medicare and Medicaid: 20–50 calendar days
mentor: Medical Turnaround Time Expectations - PCC
How many are we on the team effective November 2021?
11
Roselyn Carmen will be effective with use on November 2021, but we are already including her as of this month due to CCS transition for L1.
PPI # 1-800-438-7885
internal # 1931910
What is the Classification and Intent to use "when advising how to make demographic updates"
Classification: Provider
Intent: Demographics
What is our NPS Passing Rate for October 2021?
Passing Rate: 60.00 %
Exceed Rate: 63.00 %
---------------------
TIER 1 - 85.01% - 100.00%
TIER 2 - 65.00% - 85.00%
Do we have a FAX # for appeal submission?
YES, but SHOULD NOT BE proactively offered
For Appeals, CCS should not proactively provide the correspondence fax number for the submission of the appeal. The mail option should be given first to the caller. If the caller would ask for the fax number CCS may provide the (888) 556-2128 but they should still inform the caller that the preferred method for the submission of appeals is thru mail based on the documented process in Mentor document Provider Grievance, Appeal, and Complaint or Dispute Overview for PCCs
source: eMARS Update
EDEN FYI2021 - 39 Humana Correspondence Fax number
When will you have a Citation Form for Overbreak?
Which ever is met below:
1. 3 instances even if less than 15 minutes
2. More than 15 minutes, 1 instance or up
What is the threshold for
ACW and Hold Time?
ACW: 60 seconds
Hold Time: 120 seconds
What is the TAT for Correspondence review?
30-60 calendar days from the received date
mentor: Medical Turnaround Time Expectations - PCC
What is the Quality Passing Rate?
QA Passing: 95.00 %
-----------------------------
Reward's Goal: 98.00 %
What are the mentor documentS we can use for CE DENIALS?
Code Edit Issue Log
EX Code Guide - PCC
What is the passing AHT and REQUIRED Minimum ACD per day?
AHT: 700 seconds
ACD: 39 calls / day
ACD Break Even: 28 calls / day
What is the escalation VDN # for sup call transfer?
186-0328
What is the process to update demographics for
INN Behavioral Health Provider?
STEPS:
1. Explain that all demographic requests must be submitted in writing.
2. Provider the caller with the email address behavioralhealthproviderservices@Humana.com
mentor: Provider Issues for PCCs
Allowed Amount: $ 1000
Humana Paid: $ 600
Mbr's Responsibility: $ _____
How much is the member's responsibility?
Mbr's Responsibility: $ 400
Allowed Amount - Humana Paid = Mbr's Responsibility
$ 1000 - 600 = $ 400
What is the Classification and Intent if the provider is calling for STATUS OF MEDICAL RECORDS sent?
Classification: Claim Status
Intent: Medical Records Search
mentor: CRM Classifications and Intents - PCC
What is the TAT for EOR via FAX?
1 - 5 business days
mentor: Medical Turnaround Time Expectations - PCC
Explain the complete guidance for Medicare Corrected Claim Submission
adv Medicare providers can submit corrected claims via For MAIL - Note: Corrected Claim on the top of the form or Electronically-change frequency code into 7.
/attn: Humana Correspondence /
ADD: PO BOX 14601 Lexington, KY 40512-4601/
Once received TAT:20–50 calendar days from the received date/
corrected claim standard timely filing Medicare replacement plan : 12 months from the original processed date /
Provider is requesting a copy of their fee schedule or clarification on their fee schedule when NO CLAIMS are involved. What is the process?
1. Create a CRM case with the provider as the inquiring about and for.
Note: Specify in the comments that a copy of the fee schedule is needed. It needs to be very clear that any claim research is separate from the reason for the inquiry being sent.
2. Send the CRM case to the HBH team:
******Service Center: Market
******Queue: National Network Ops
******View: Humana Behavioral Health
>MAKE SURE to follow the TEMPLATE in mentor document: Provider Issues for PCCs
What is the Maximum Out Amount you can get in Exceed?
P 6,000.00
Disclaimer: This varies on the rewards we are getting if the program is hitting NPS and Quality
For PCI DENIALs like 15F, 7MX and others that are already OVERTURNED but NOT YET REPROCESSED.
Question # 1 - Where/to whom should we send the request to apply the determination?
Question # 2 - What is the TAT to provide?
Answer # 1 - to PCI Tank
Question # 2 - 60 calendar days
what is the Suggested VOC Survey Script?
Please stay on the line for the opportunity to take a quick/brief survey about your experience during this call