Authorization quiz : Providence

What is the purpose of the follow-up activity with code 94401 in EPIC, and what are the steps involved in updating the BDC of an account?

• Purpose Only:

  1. The follow-up activity is used to generate reports in EPIC.

• Purpose and Steps:

  1. The follow-up activity is used to update the BDC of the account in EPIC.

  2. Steps involved:

     • Open the account on Epic.

     • Click on the Liability tab.

     • Click on the outstanding invoice.

     • Click on Follow up.

     • Select your denial (if it is not already selected).

     • Click on Follow up activities.

     • Enter the code 94401.

     • Press enter.

• Steps Only:

  1. Open the account on Epic.

  2. Click on the Billing tab.

  3. Click on any invoice.

  4. Click on Follow up.

  5. Enter the code 12345.

• None of the above.

What is the primary purpose of the "Auth/Cert" field in the context of claim processing?

• To provide an overview of encounter information and scheduled procedures.

• To list all referral and authorization notes in chronological order.

• To serve as the primary authorization/certification field for Inpatient and Outpatient surgeries, Inpatient Admits (IP), Observations (OBS), Extended Hospital Outpatient (EHOP), and Ambulatory Surgery (HAS).

• To store scanned copies of authorizations in the Registration > Documents folder.

Where can you find a scanned copy of the authorization for most Outpatient accounts?

• In the History Tab under the 'Auth/Cert and Referral Notes' section.

• In the Registration > Referrals section.

• In the Claim Image: UB-04 claim Box 63 / CMS-1500 claim Box 23.

• In the Registration > Documents folder.

What should an associate do if an authorization number, such as 2400700081, is denied for reasons such as missing or invalid authorization number, and it does not fall under the date range or is not related to services?

• Send a technical appeal immediately without further investigation.

• Confirm the correct authorization number and investigate why the authorization 2400700081 is denied.

• If the authorization or retro authorization is not available at the insurance end, send an appeal as per appeal guidelines.

• Call is not required to validate the authorization number.

What should be done if a claim is denied due to "No auth" and is not appealable because the amount is less than the threshold of $500.00?

• Send an appeal for the claim regardless of the amount.

• Write off the claim amount since it is not appealable due to being below the $500.00 threshold.

• Place a request to send an appeal for the claim.

• Increase the claim amount to make it appealable.

What is the appropriate action to take if an insurance company denies a claim for "No auth," but it is indicated in EPIC under the "Auth-CERT TAB" that authorization is not needed?

• Accept the denial and close the claim.

• Send an appeal for the denied claim.

• Call the insurance company to get the claim reprocessed, as authorization is not needed.

• Ignore the information in EPIC and obtain a new authorization.

What steps should be taken when a claim for CPT J9046 is denied as CO197, with no denial level information in the notes, and partially denied for CO 56 with the reason "PX not proven effective"?

• Accept the denial and close the claim without further action.

• Only follow up on the CO-56 denial and ignore the authorization denial.

• Conduct a complete review and follow up on both the CO-56 denial and the authorization denial with the payer.

• Resubmit the claim without reviewing the EOB or denial reasons.

What steps should be taken when a claim is denied for TAR, and there is no TAR on file?

• Resubmit the claim without making any changes.

• Update the billing edit as stop bill with account activity 208 and billing indicator 10069, so the TAR team can review and rebill the claim once the TAR is approved.

• Close the claim and mark it as unresolvable.

• Send an appeal without updating any billing information.

What should be done if a claim is denied for authorization, there is no authorization on file, the payer does not accept retro authorization, and the amount is less than $1500?

• Send an appeal for the claim.

• Write off the claim using the Cost to Collect Tcode.

• Refer the claim to DR UM for review.

• Pend the claim for 30 days for appeal.

What is the procedure if a claim denied for authorization has an amount greater than $1500 and is an outpatient claim?

• Write off the claim using the Cost to Collect Tcode.

• Refer the claim to DR UM for review.

• Refer the claim to a Nurse auditor.

• Pend the claim with the header Retro Auth/Referral - Pending for training for 30 days.