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ASO Final Flashcards | StudBud
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ASO Final
ASO Final
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Questions
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Answers
1
What does a claim in 02 status mean?
denied claim
completed claim
paid claim
in process
2
For member #3 claim for Terrence Sedgewick what is the member responsibility?
$947.70, as Deductible & Co-Insurance
$0
$105.30, as Co-Insurnace
$105.30, as Deductible
3
CPT code 99213 does NOT require a Prior Authorization
True
False
4
For member #3 claim for Terrence Sedgewick what is the paid amount?
$105.30
$947.70
$2,418.00
$0
5
If a member has duel PHP does a provider need to submit their claim twice?
no
yes
6
The provider portal is call ProvLink.
False
True
7
Can a Naturopath provider submit referrals to specialist?
yes
NO
Only if at a PMG cllinic
8
Using member #1 is provider Wade Keller (zip 83616) in network, if so what network?
yes, CIGNA
no, out of network
yes, EPO
yes, PROVCHOICE
9
What are the next steps for clinical edit z45?
Clinical Edit Inquiry Fax
Provider must re-bill with corrected CPT code or units
Provider must re-bill with appropriate modifier
no action needed
10
Confinement authorizations are for inpatient hospital and skilled nursing facilities
False
True
11
Using member #2 is provider Lisa Pool (NE Kearney) in network, if so what network?
yes, CIGNA
no, out of network
yes, EPO
yes, ASHN
12
When verifying National Network providers you should always utilize the directory
True
False
13
Select all groups that cover elective termination of pregnancy
Benchmade Knife
SAIF
Nosler
PEBB
14
What is the main function of our Health Care Services (HCS) Department?
Enter claims in Facets and processes claims
All of the above
Review High Tech imaging Prior Authorizations
Review Prior Authorization requests and claims for medical nesessity
15
How does PHP utalize Evicore for the CIGNA network?
Hearing Aids and Hearing Aid provider network
Review PA’s for Physical Therapy
Review PA’s for High tech imaging.
Review PA's for medical services
16
What is the PHP Claims Fax #?
503-574-5920
Fax 503-574-8149
503-574-5940
503-574-7500
17
What makes a group an ASO group is cause the employer pays for their own claims
False
True
18
Which Facets application does customer service use to view specific details on authorizations including HCS notes.
Medical Claims
UM History
Prospective UM
Subscriber Family
19
What is timely filing for an initial claim submission from most providers, and members?
12 months from the DOS
90 days from the DOS
18 months from the DOS
180 days from the DOS
20
For member #7 The referral for Dr. Downing Moore includes OV, Surgery, DME, INJ and diagnostic
True
False
21
What reminders do we tell members who have ordered ID cards?
Plain white envelope, 7-10 days to arrive
Clearly marked envelope
Plain white envelope, arrives within a week
about a week to arrive
22
For member #7 What is the active referral number for Emily Downing Moore?
191370137
220870340
220870184
There is no referral
23
What benefits should we offer if a member goes to the Chiropractor?
Chiropractic Manipulation and rehab (PT/OT/ST)
Specialist OV, Xray/Lab, Chiropractic Manipulation, Rehab (PT/OT/ST)
Alt Care OV, Chiropractic Manipulation, Orthotics
Alt Care OV, Xray/Lab, Chiropractic Manipulation, Rehab (PT/OT/ST)
24
PEBB Choice and Benchmade members medical home must always be verified.
False
True
25
What vendor is used for routine vision?
ASH
VSP
Clarity
AIM
26
What tool is used to look up providers and facilities in Oregon/SW Washington?
Directory
Facets
ProvLink
AIM
27
What is Cigna's claims address & Payer ID?
PO BOX 188061 Chattanooga TN, 37422 Payer ID: 62308
PO BOX 3125 Portland OR, 97208 Payer ID: PHP01
PO Box 30805 Salt Lake City, UT 84130 Payer ID: PHP01
PO Box 60007 Los Angeles, CA 90060 Payer ID: SX133
28
Do PEBB members have massage coverage?
No, no coverage at all
Yes, ONLY Choice
Yes, both Statewide and Choice
Yes, ONLY Statewide
29
What Facets application do we use to check for consent?
Member notes
Claims inquiry
Member Authorizations
Prospective UM
30
What action does clinical edit u13 need?
Provider must re-bill with a corrected HCPCS/CPT code
Provider must re-bill with corrected modifier(s)
Clinical Edit Inquiry Fax
Provider must re-bill with corrected diagnosis
31
What fax number does a
participating
provider use to appeal clinical edit denial z58?
503-574-8146
503-574-8609
503-574-7500
503-574-7940
32
How long do providers have to submit a reconsideration in Oregon?
24 months from the denial or partial payment date
12 months from the denial or partial payment date
18 months from the denial or partial payment date
6 months from the denial or partial payment date
33
What should your summary ALWAYS be when documenting a claim?
Provider name
Date of Service
Date of Service and Billed amount
Date of Service and Provider name
34
For member #6 What is the Original effective date?
01/01/2010
10/01/2010
12/31/2009
01/01/2021
35
For claim #4 What is the denial reason?
It didn't deny
Claim was submited too late
No prior authorization
Member went out of network
36
What instructions should we give a provider who would like to submit a corrected claim?
Send the claim to HCS for review: write Corrected Clm
Resend to claims: Submit it Electronically
Send it to A&G for review: Circle corrections, drop to paper.
Resend to claims: Drop to paper, circle corrections and write Corrected Clm
37
If PHP is a member's secondary insurance would we require a PA if the primary allowed the service.
Yes
No
38
We are able to update a members address.
False
True
39
PHP does not accept retro prior authorizations.
True
False
40
How long does a member have to appeal a denied PA? How long does PHP have to respond to the member?
30 days from denial - 30 days to respond
60 days from denial - 30 days to respond
One year from denial - 30 days to respond
180 days from denial - 30 days to respond
41
Providers have to bill Full Global for maternity services
True
False
42
What is the clinical edit z60 action needed?
Clinical Edit Inquiry Fax
No action needed
Provider may submit medical records to HCS for reconsideration
Provider must re-bill with corrected diagnosis
43
Where should active members be directed to update their address?
Transfer to TS
The employer/HR
Membership Accounting
MyProvidence Account
44
Using member #1 is doctor Sandra Chern(zip 98405) in network? If yes, what network?
yes, EPO
yes, ProvChoice
no, out of network
yes, Cigna
45
What do we use the vendor Amplifon for?
Cigna Network - Amplifon is used to review for PT/OT services
Cigna Network - Amplifon is used to review PA's for medical services
Cigna Network - Amplifon is used for hearing aids + hearing aid providers
Cigna Network - Amplifon is used to review high-tech imaging PA's
46
PEBB offers coverage for weight watchers.
True
False
47
For claim #5 Was the provider in network?
yes
No
48
For claim # 5 The provider can balance bill the member
True
False
49
A referral is required if the primary insurance does not require one but the member’s secondary plan is PEBB Choice
True
False
50
What fax number does a
Non-Participating
provider use to appeal a clinical edit denial?
503-574-7500
503-574-8146
503-574-8609
503-574-0000
51
Where does a EPO provider submit a PA for high tech imaging?
HCS
AIM
ProvLink
Evicore
52
What do modifiers 26 and TC stand for?
26 - Pro fees, TC - tech component
26 - radiology charges, TC - Hospital charge
TC - tech charges, 26 - member requests copy of images
they both stand for radiology, same thing
