Burgess/Healthedge
These bill types are commonly associated with Hospital Outpatient Department (MC03) pricing
131-138
For members age 19 and older, qualifying vaccine procedures are billed (with/without) which modifier
Without modifier SL
Which CPT code range is used to identify Physical Therapy, Occupational Therapy, and Occupational Therapy claims?
97001–97546
What key function attaches a PA to a claim in IDX?
F10
Allowed amount is calculated as?
Payment + PR
What should a processor do when they encounter HealthEdge error 003396 (invalid/missing provider)?
Pend to system review and escalate
All vaccines are required to be billed with valid administration codes? (T/F)
True
Outpatient Physical Therapy for members age 21 and older is limited to how many visits per contract year?
15
Which disposition is used when a procedure code does not match the PA?
#12 - Unauthorized treatment
Which CARC group represents Patient Responsibility
PR
What is the correct action when HealthEdge produces an incorrect denial for a bundled outpatient procedure (002839)?
Which administration code is used for “1 vaccine” when administered by intranasal or oral route?
90473
Outpatient Speech Therapy is covered only for which member groups?
EPSDT, KidsCare, and ALTCS members
What disposition is used for denied or closed PAs requiring authorization?
#22 - Referral not approved
COB for UB claims is applied at which level in IDX?
Header level
How do you view edits and pricing in IDX? (for UBs)
F9 key > 2-Burgess > page down
After DOS 5/11/23, which administration code must be used to report COVID‑19 vaccinations (with required documentation)?
90480
CPT code 92507 requires special processing for which member group?
AzEIP members
What does NMN status mean?
Not medically necessary
When more than 8 adjustment codes are present, the processor should?
Combine similar codes into one line
For AHCCCS UB-04 claims, the 003681 edit (maximum allowable daily units) is handled how?
Partial units may be approved and remaining denied
If an NDC is not billed on a claim for vaccination CPT/HCPCS, the vaccination code will deny as?
#275 – NDC INFORMATION MISSING/INVALID/REQUIRED
Speech Therapy services must be billed under whose NPI?
Individual SLP NPI
What does selecting “L” from the referral screen display?
Linked claims/invoices
For outpatient claims with a negative Medicare Part B payment, which CARC is used for the negative amount?
CO-94