QA Deductions from September
True or False: PT/OT/ST is combined for a 20-visit limitation.
False, each therapy has their own visit limitation seperately
What department sends a member verification letter?
Correspondence
What are the Open Enrollment dates for Walmart 2025 benefits?
Walmart Open Enrollment 2025 is October 12, 2024 through November 8, 2024.
Call is about Effective/Eligibility dates only
Eligibility/Benefits - Eligibility
Who is the vendor for mental health/substance abuse?
Lucet
What must you confirm on ALL provider eligibility calls, even when the benefits are not given?
Network/Participation Status
What form does a provider fill out for a Network Exception?
Authorization/ Organizational Determination Request Form
What are the national benefit changes to the Premier, Contribution, and Savers plans for 2025?
None
Member needs My Blueprint password reset?
My Blueprint - Password
Who is the vendor for a Health Savings Account?
Health Equity
What department, product line, and team, do we route COB information?
Customer Accounts, BANA - Walmart, and Walmart COB
What does DRG stand for?
Diagnosis Related Grouping
When will the 24-hour nurse line no longer be available?
12/31/2024
Calling to see how a claim has been processed
Claims-Status
Who is the vendor for pharmacy?
Optum Rx
Definition: Is the act of transferring a call to someone in a polite fashion by asking the caller to "please hold" and then announcing the caller to the person he or she wishes to be transferred to.
Warm Transfer
The timely filing for out of state providers?
Out-of-state contracted providers have 18 months, or based on their contract with the local blue, whichever comes first.
When is a $300 copay waived for ground ambulance services in 2025?
There are 2 answers. You will only be rewarded half the points if you only answer 1.
Member is trying to locate an in-network/Preferred provider; Member Needs to verify provider network status.
Provider Information - Participation Status
Who is the vendor for Fertility & Virtual Doula Services?
Kindbody
If a provider is calling to check the status of an Outpatient PA for cpt code 66984 and you are unable to locate the PA. What is your next step?
Check the cpt code in medical code Search
In what instances do we offer a Pre-Service Appeal?
Carelon (formerly AIM) denials are the only pre-service denials that an appeal will be accepted for.
If a member is transported via ambulance to the ER, but not admitted to the hospital, will both the ambulance copay and the ER copay apply?
Yes, the ambulance and ER copays are separate. It is possible that someone could be responsible for an ambulance copay and then also an ER copay.
When you transfer a call to another area and did not provide any eligibility, claims, or benefits.
Redirect Call - Transfer
Who is the vendor when your back is broke?
Contigo Health