Looming Liability
What are some common factors to consider when determining liability?
Remark codes, Provider Comments, Provider network status, Submitter
For ERISA document request what would be the Issue Category?
ERISA document request
True or False : Are these Remark codes - HR, IQ, KC, and OO considered FWAE?
False
Aside from Nike and Apple, what other issue does the Authorized Rep Process not apply to?
Pharmacy
Which Macro do we use to verify PG policy?
Ctrl 9
A claim last processed after 01/19/2024, what will be the liability for a par provider with O8 remark code?
Provider liability
Fully Insured policy, which two SOG provide first level as Hearing?
SOG WI, DC (except for FEHB - Federal Employee Health Benefit)
If the issue is related to a claim with a Chartpoint closure code GJ/GX or processed with a Chartpoint remark code U2, UJ, S7, or 5I (alpha) where does it need to be routed if reconsideration is not completed?
550 FRD FAC
True or False : For UHC Form, If the required information is anywhere within the submission related to the member authorization, it will be acceptable.
True
True or False : All Railroad policies are PG policy
False
Note: Only 23000 policy is PG, other Railroad policy 690100,46000,23111,107300 are NOT PG policy
Par Provider appealing claim that processed with OIM line. What will be the liability?
Member liability
If you have market type 15, which SOP would you reference to find Product type in ETS?
Charter Compass Navigate NexusACO and HCR Exchange SOP
In the FWAE SOP, what must apply for a claim to be considered Inpatient?
Place of Service is inpatient Hospital, and claim is billed with rev codes.
True or False : If authorization received on 1st Level Appeal, it will also be valid for the 2nd level.
True
Where can you look to find directions on How to Search for a purged claim?
The Triage Research Guide SOP (Looking up a Purged Claim in Doc360)
If the claim has 7Y closure, How do we determine liability for case?
Using provider network status
If you have an Optum Behavioral Health case, What Issue Type should you use?
1st level appeal
What are some common FWAE Closure codes?
FJ, FT, FO (alpha), G1, KT,KS,KM
What is one system we can access to determine if a member auth is on file?
Doc360, ORS, ETS, UNET FCI screen, IDRS, EIM, CIRRUS
Which criteria do we use to verify claim information on Purge claim record?
CPT code, Provider Tin, Date of Service, Claim dollar amount
Out of network Provider appeal the claim with notification penalty, who will have the liability?
Member liability
Where do we look for provider reconsideration?
ORS, PIQ, PICTS, ETS case or letter generation ID.
What is one items to look for in PICTs to determine the Optum denial allows for subsequent review?
1)Case Status is Closed and Case Status Reason Findings, 2)Review the Note tab for mention of hard denial, 3)Review the ORS for mention of hard denial
If claim is processed with NSA remark code and an ERISA request is received. Does the ERISA require member authorization?
Yes
Note : if the submission is not from the member or an individual listed on the policy
When you run the CRT macro, is ICN EG89114140 part of a CRT project? If so where do you route it?
It's an Apple policy (700406), CRT procedures would not apply to Apple nor Nike per Step 15 of our Triage Intake SOP