Provider
What are PPO, PAR, and NP?
What is Standard, Basic, and FEP Blue Focus?
This is the medical review dollar threshold.
This is an edit issued by the local plan.
The program used to obtain manual pricing allowances.
What is FACETS?
Despite often being billed with a rendering provider, claims for this government entity are processed using the Group Clinic PRPR.
What is the VA?
Name one location where we can find nicknames when they are on file.
What is the Member Roster: More, Special Info, Misc Notes, or Previous Name?
What is Registrar MMTUSER?
This team reviews flagged providers to prevent possible cases of fraud.
Who are External Audit?
If you deny only one line of a multiple line claim, what important step must be taken?
What is Set RPI to Y on all lines?
These are the fields needed to perform an initial provider search.
What are TAXID, NPI, and Date of Service?
The three major items needed to match a member.
What are Name, Date of Birth, and Address?
These three items must match between your CCA case and your claim.
What are TAXID, CPT Code, and Date of Service?
This system stops pre-deferrals.
What is the Bridge Console?
When manually pricing, the remote pricing indicator must always be set to...
What is RPI N?
This independent lab often bills within Utah and has special processing instructions.
What is ARUP?
This box must be unchecked when searching for a member by name and date of birth.
What is Select Contract Holder Only?
What is the Medical Review Indicator?
Why do General Bridge Logic deferrals exist?
What is "the local plan has special processes and criteria that must be reviewed by an analyst"
This must be populated on all payable lines to successfully manually price a claim.
What is the Pricing Allowance Field?
The reason it is important to submit Provider deferrals with RPI Y.
What is "to obtain correct pricing per the provider's contract"
This is where we can look to tell if a member is or was enrolled under a different policy number.
What is Additional Member Eligibility?
These fields must be populated when a claim requires prior approval.
What are Prior Approval Indicator and Type?
These GBL deferrals often need to be reassigned to analysts trained to work them.
What is DME?
The claim threshold for second level review when manually pricing professional and facility claims is...
Facility and non-Medicare Professional claims: $100
Medicare Professional Claims: $50