Pre-Determinations

FARM ESCAPE ROOM

Help on the farm with daily chore

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Chickens and their eggs

Collect chicken eggs for each correct answer

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Collect

question 1/4

"Hello, my name is Susan. I am calling to follow up on a member's pre-determination status." Pick your response:

"Susan, please call the member for this information."

"Hello Susan, I can transfer you to the correct department for assistance."

"Sure Susan, I can definetly assist you with pre-determination status."

Collect

question 2/4

"First, can you please provide me...." What information do we need to collect from Susan to complete the caller portion in D365?

First inital to her last name, call back #, name of the office, NPI.

First inital to her last name, call back #, name of the office, NPI, member ID & member name.

First inital to her last name, call back #, address.

"Thank you for providing that information Susan, I do need to ask you a few questions to protect the member's privacy. May you please provide me...." What information do we need to collect from Susan to complete the member portion in D365 and verify HIPPA?

question 3/4

Collect

Member ID #, member's full name, member's date of birth - if not subscriber also collect subscriber's name, DOB, and relation.

Member ID #, member's full name, date of birth.

Member ID #, member's full name, date of birth, complete address.

question 4/4

"Thank you for verifying the members information Susan. Let's take a look at your pre-determination...." What information should we ask for to locate the pre-determination?

Collect

What is the name of the doctor or facility you are submitting it for?

When did you submit the pre-determination, what services was it submitted for?

Nothing - just move forward and try to locate the pre-determination on your own.

Cluck, Cluck...

Well done! Happy chickens

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Cows and their milk

Milk the cows for each correct answer

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QUESTION 1/4

Now that we know when it was submitted, what is the best place to confirm we received the pre-determination?

Milking

Electronic Documents - eDocs

Correspondence History

Member Notes

QUESTION 2/4

We were able to locate the pre-determination was received on the date specified by Susan, what do we do now to determine the status?

Milking

Check member notes for status update.

Check eDoc notes, description and Claim Investiation Detail screen.

Send this information back to HB Claims queue and request they provide a status update.

question 3/4

Great! We found the notes directed us to the Claim Investigation ID #! If the Claim Investigation ID # was not provided in the eDoc notes, how can we determine what Claim Investigation to select?

Milking

Check the dates and open to check if that eDoc is listed under Routable Images.

There is only one, select that one and assume it is for the pre-determination Susan is calling about.

Choose the most recent one listed since this is the most recent pre-determination submitted.

question 4/4

We opened the correct Claim Investiation ID # and determined the pre-determination was approved. What do we tell Susan?

Milking

Susan, I was able to locate the pre-determination and found it was approved for (service) as of xx/xx/xx. A letter was sent to the provider on xx/xx/xx.

Susan, I located the status of the pre-determination and found it was approved.

Susan, based on the located information, I am unable to provide you an update on the status.

Mmoooo...

Well done! Happy cows

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Pigs and their food

Feed the pigs for each correct answer

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QUESTION 1/4

"That is great news, I will look out for that fax. Can I also verify eligiblity for this member?" What would we select in D365 for this information?

Feed

The member is currently active with an original effective date of 1/1/2021

The member is not active, the policy terminated on 12/31/2022.

The member is currently active with an original effective date of 1/1/2023.

QUESTION 2/4

Click on the photo to see what populated on the benefits & eligiblity screen. What is the correct response for the eligibility verification?

Feed

QUESTION 3/4

"Great, thank you for your assistance. May I please get the reference number." Where in D365 would you locate this information?

Feed

"Thank you for calling, hope to hear from you soon!"

"Bye, talk to you later."

"I'd like to remind you that you have the opportunity after our call to let us know how we did for you today. Would you like to give us feedback by answering 2 breif questions?"

QUESTION 4/4

You have provided the case # from the summary tab in D365. After the caller stated there was nothing else you can assist with, how do you end the call?

Feed

OinK, oink...

Well done! happy pigs

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Sheep and their wool

Shearing sheep wool for each correct answer

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BONUS question 1/4

What else may the provider say to refer to a pre-determination? Choose the best answer.

Shearing

Pre-d, pre-authorization, pre-certification, prior authorization.

Pre-destination, fixed determination, presumption, pre-treatment.

If the provider does not say pre-determination then I will not check for a pre-determination.

question 2/4

Should we offer a pre-determination to a caller?

Shearing

No, we should advise services are subject to medical necessity and eligibilty.

Yes, if this is a high dollar service.

Yes, if this is a service you cannot verify to be covered.

question 3/4

Can a pre-determination be submitted for a excluded service?

Shearing

Yes, only if it is to request additional visits to maximum benefits such as PT, OT, ST.

Yes, only if it is medically necessary.

No, a pre-determination will never override a benefit exclusion.

question 4/4

In what case would a pre-dertermination be considered urgent?

Shearing

The member is going on vacation and needs treatment before they leave.

The member is in need of chemo-therapy.

The member has an upcoming appointment.

Beeeehehe...

Well done! Happy sheep

continue

All right, daily chores done!

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FInalize

CONGRATULATIONS!

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It got dark and you haven't finished your daily chores!

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