DME
The VENDOR responsible for DME distribution for our members in Oregon and SW Washington.
*BONUS: What is their phone number?
Providence Home Services
*BONUS: (503) 215-4663
Certain immunizations are not covered due to these purposes. (WHY the member is getting them done...)
What are "Immunizations/Vaccines for Travel, Work or School"?
The vendor used for our alternative care network.
What is American Specialty Health network (ASHN)?
The healthcare reform influenced the way that contraceptive services were covered in this way.
What is "covered-in-full"?
The reason why we cannot change the address for MBR ID 100205804-00.
What is EDI group?
The location code/place of service code which indicates "Patients Home".
What is POS 12?
The age a member needs to be in order for no PA to be required for a Zoster/Shingles vaccination.
What is 50?
The benefits needed to quote for a member calling for chiropractic benefits.
What are: Chiropractic benefits, OV to an alternative care provider, xrays/labs and outpatient rehab.
The 5 groups that are religiously exempt from covering contraceptive services in full.
What are:
1. Oregon Catholic Press
2. Franciscan Montessori Earth School
3. Mt. Angel Abby
4. Archidiocese of Portland
5. LaSalle Catholic Press
The 2 things we need to tell members when ordering an ID card for them.
What are:
1. It will arrive in 7-10 business days
2. It arrives in a plain white envelope
The dollar limit for foot orthotics for MBR ID 100440588-00.
What is $200?
The type of HCPC code billed for medications relating to injections.
Hint: It's a letter..........
What are "J-codes"?
The alternative care benefits allowed for MBR ID 100951349-00.
What is "OV to an alternative care provider" and outpatient rehab and/or diagnostics. (No chiro/acup benefit)
The diagnosis that needs to be billed for an IUD in order for it to be covered-in-full.
What is "contraceptive"?
The CPT code that is for venipuncture/actual drawing of blood.
What is CPT code 36415?
The benefit that lancets and test strips fall to for members with diabetes.
*HINT: Diabetic supplies or DME?
What is the diabetic supplies benefit?
The benefits needed to quote for an in-office injection.
What are "Injectable Medications" and "Surgery/anesth (in office)"?
BONUS bragging points: If you included an office visit benefit as well!
The alternative care plan type that allows members to see any willing provider for chiro/acup for in-network benefits; but any ancillary services fall to the applicable network for that provider. Example: Chiro falls to in-network benefits, but provider is nonpar with ASHN so any modalities fall to the OON rehab benefit.
What is the "Alternative Care Plus Plan"?
The benefit(s) that apply for grandfathered plans for Implanon/Nexplanon.
What are:
1. Device: DME
2. Insertion: Surgery benefit
3. Removal: Surgery benefit
The answer to whether or not a prior authorization is required for CPT code 95974, nerve stimulation.
What is "Yes"?
Bonus: How does a provider submit the request?
The POS that needs to be billed for HCPC code A7034 to be covered.
*BONUS: Is a PA required?
What is POS 12?
*BONUS: No
The benefit quote for MBR ID 100129262-00 receiving an in-office injection for J1720.
What is:
OV: $15 CP, ded waived, up to $2000 oopm
Inj Med - $500 ded, 20% coins, up to $2000 oopm
Surgery & Anesth - $500 ded, 20% coins, up to $2000 oopm
J1720 - Payable, no PA required *QPAD*
The reason we paid $0 on CL 180784160600.
*BONUS: Whose responsibility does it fall to?
What is "not a covered benefit"?
*BONUS: Member responsibility
The HCPC code billed for a Skyla IUD.
*BONUS: Does it require a PA?
What is J7307?
*BONUS: No, IUD's do not require PA's.
The number outpatient rehab visits that MBR ID 100156264-00 has remaining for this year.
What is 17 visits?