Auths/Referrals
What Does PFP Stand for?
Physician Finder Plus
What Platform do we review on the Code Edit Explanation Code List
CAS
Name 3 documents that are required to be attached to the case/efile before sending to IRT.
IRT Checklist
Chapter 3 EOC
Resolution Letter
Complete EOC
What document is needed to determine if a member has met their MOOP or Deductible.
Deductible Spreadsheet
Which Vendor do we send PDPM reviews to.
What modifier do you use on the MHI screen in CAS to determine if there is an Auth/Referral linked to the claim.
R Modifier
Name 3 Vendors
ClaimsXten (CXT)
Cotiviti PPM/CV
Optum (OPT)
LCD/NCD
What is the correct subtask used if the denial is a Code Edit Denial.
IRT Initial Review Code Edit Review
What is reviewed to determine whether the correct Cost-Share is applied.
Evidence of Coverage (EOC)
Name 3 places you can locate the member's PCP
Blue Banner
J Modifier
CI/PAMG
What document do you review for the denial code, to determine if the denial is stating that the Auth/Referral was Not received, Not matched or Not approved.
CAS Deny, Mpay, and Pend Codes Master
ClaimsXten: What modifier do you use at the end of the MHI screen to check to see if there is a referring claim causing a denial on the appealed claim.
Modifier HGM
True or False
If the Subcategory reflects other, than an explanation should be added in a case note.
FALSE
True or False:
Once 3 outreaches are made to the member to explain the outcome of the balance billing case can be dismissed.
False: Only 2 outreaches are needed
True or False
You can use the CAS Deny Master Document to assist with Sub-Category Options
True
Which member plan may direct you to review the Prior Authorization List (PAL)
PPO Plan
Name two Business Partners that may need request for additional review for the code edit on the claim.
MCCAU and CEVM
True or false
7-10 business days are needed for cases due under day 50.
False
True or False
If the accumulations determine that the member is over their MOOP/Deductible limit, the next step is to submit to CRU for reprocessing.
False: A Ticket needs to be created
What procedure is reviewed for appeals involving (just to name a few) work related, vehicle, assault injuries.
Subrogation
True or False:
If the approved referral is for the same group as the facility provider on the claim image, this is a match when the service and date of service (DOS) match.
False
Has to be the Billing Provider
What is the purpose of having the Code Edit Procedure in Place.
*To identify when incorrect procedure code combinations are reported.
*Reduce and eliminate improper claim payments
What needs to be attached to the case when reviews are completed by the MD.
Documents cited by the MD
If a Non-Contracted provider is billing the member, then what needs to be determined.
If they accept Medicare assignment.
What are two places you can locate an approved or denied authorization for a claim.
CGX and PRI Screen in CAS