What will clicking the blue hyperlink do?
Takes you to another page
What list lets you see cases accessed on the previous day?
Recent Work
What does orange insurance text on the journal page indicate?
Entity comments are available
If you click on the account number in PAS, what page will it take you to?
View/Update Patient page
What can be customized by client to move cases through the reimbursement process?
Workflow
What are the three principles of EDG?
Partnership, Transparency and Convergence
What are Connections, Codetable and CANS messages?
Publications of EDI/EDG
What are two purposes of the Xpeditor edits?
Clean claims and claim adjudication
What are the three purposes of EDG?
Verify, Clarify Simplify
What are four valid documentation sources used to justify edits?
UB Editor, Payer Alerts, ANSI 837 specs, Payer help desk
Which work list is used to notify the doctor of benefits investigation information and the patient's decision of whether or not to proceed with testing?
MD Notification of BI
What status is selected when a task on a work list is finished?
Complete
What work list is worked by an outsource company, making calls to the insurance companies?
Pending BI
What automated work list sends queries five times per day?
ELEL -- electronic eligibility
What two ways can a case be added to a work list?
automatically and manually
What is L06?
unbillable insurance code
What is a group of cases at the same point in a workflow that require similar action(s)?
Work list
How does the client send demographic and charge information to Quadax?
via a load file
What is electronic eligibility?
ANSI 270
What is the list of four items that need to be completed during the pre-billing process called?
Pre-claim requirements
What is used to duplicate keyword fields in OnBase?
F6 or double-clicking
What are small images of separate pages in a document at the bottom or side of the screen called?
thumbnails
What database stores client documents if the client does not purchase an individual database?
OB-server
What is the process of assigning keywords to a document called?
Indexing
What is entered in place of a keyword to assist in a search?
wildcards
If the insurance name is in red text in a work list, what does this signify?
That there is a pre-claim requirement
What is considered the centerpiece of PAS?
Journal
Where are claims generated in PAS?
The View/Update Insurance window
What is the only location where new insurance information may be added to an account in PAS?
The View/Update Patient window
If I do not have a contract with a patient's Blue plan, where will I submit a claim?
To the plan in the state where the specimen was drawn.
If I click on the case number on a work list, where will it take me?
The Journal page
What PAS components are available to clients for customization?
Benefit Investigation
Prior Auth
Claims Processing
Ordering Physician
Appeals
Patient Responsibility
What is the purpose of the SOPs?
They provide direction on client-specific processes
What is the dotted underline for?
Provides a 'tool tip' and gives information on a mouse over
What are icons for?
quick identification; represent different actions
What are different text colors used for?
Colors indicate text comments and identification of information
What are the four main pages in PAS?
Patient Lookup
Journal
View/Update Patient
View/Update Insurance
Where can you add a new insurance in PAS?
From the View/Update Patient page only
In PAS, what is status is WHITE?
Open
In PAS, what is status is YELLOW?
Priority
In PAS, what is status is GRAY?
Wait
In PAS, what is status is RED?
Hold
If you are in a work list and click on the case number, where will you be taken?
Journal
If you are in a work list and click on the account number, where will you be taken?
View/Update Patient page
What are the three sections of the Journal page?
Case Information
Journal
Insurance Information
Under Case Actions, what does Create Document do?
compose letters, fax cover sheets, etc
Under Case Actions, what does Update Pre-Claim Requirement do?
Used when prior authorization or other pre-claim requirements are pursued
Under Case Actions, what does Start Insurance Paid Patient do?
Used when the patient receives funds directly from the payer
Under Case Actions, what does Prep Multiple Appeals do?
Used to store appeal information when no denial is received yet; may be used to start initial appeal
Under Case Actions, what does Add Appeal do?
Start an appeal
Under Case Actions, what does Add External Review do?
Start an external review
Under Case Actions, what does Add Low Payment Appeal do?
Start a low payment appeal
Under Case Actions, what does Go to Update Case do?
Update case information such as claim number, referring physician, etc.
In the Insurance Information window, what does "Contract" in RED indicate?
That there is a current contract with the payer
In the Insurance Information window, what does "Contract" in BLUE indicate?
That the payer contract has expired
What does status code W mean?
Work list created or updated
What does status code S mean?
Case status updated
What does status code W/S mean?
Work list created or updated
Case status updated
What does status code U mean?
Existing work list updated
What does it mean if there is no status code?
No action taken
What is the only window where patient demographic information can be added or updated?
View/Update Patient page
What is the purpose of the View/Update Insurance page?
make changes to existing insurance information
What are the four options for claim generation in the View/Update Insurance page?
None
Attachment (hard copy)
Demand (generated according to how system is set up)
No Claim
Where is pre-billing information derived?
Patient demographics
What is the load file?
How demographic and charge information is passed from the client to Quadax
What is the DVMI work list?
Data Verification Missing Information
What is the maximum number of times PAS will submit an eligibility request?
four
What is the ELEL format?
ANSI 270
What is the RERE format?
ANSI 271
What are the four pre-claim requirements?
Prior Authorization
Statement of Medical Necessity [SOMN]
Medical Records
PCP Referral
What happens after pre-billing?
Demos + Charges = Ticket
What is the claim follow-up cycle [timer] based on?
Client's workflow and their predetermined timeframe.
What is case status TXBI?
Billed to insurance
What is case status HSP6?
Claim in Process
What is the main function of the Insurance Staff Follow Up Work List [INSFU]?
Review and attempt to resolve any situation in PAS when the case is in a claim status and cannot proceed any further from other work lists
What are reasons for a claim being placed on INSFU list?
Subscriber not found
Missing TIN
Invalid CPT
Additional Information Needed
Duplicate Claim
Timely Filing
Request for Modifier
CPT description needed
What are two PAS work lists used for obtaining medical records?
Medical Records -- Claim
Medical Records -- Appeal
What is an appeal?
A request for reconsideration to an insurance company that denies payment for all or part of a claim
What are some valid reasons for an appeal?
Experimental/Investigational
Unproven Services
not medically necessary
No prior auth
No PCP referral
No FDA approval
BCBS Tech Assessment
Unpaid units
Non-covered
out of network
UCR
Low payment
Multiple reasons
How many valid appeal reasons are there?
13
What should we follow when deciding whether or not to add an appeal?
Client SOP
What are the three "clinical" denials?
Experimental & Investigational
Unproven services
Not medically necessary
What appeal status in BLACK?
prep or draft
What appeal status in BLUE?
sent
What appeal status in RED?
denied, partially denied, missed deadline
What appeal status in GREEN?
approved
What appeal status in GRAY?
pending
What appeal status in WHITE with BLACK background?
removed
What are the six appeal statuses?
Pending
Prep
Draft
Sent
Approved
Denied
In what area of PAS are appeals added?
under Case Actions on the Journal page
What does an appeal status of PENDING mean?
Claim has not been denied and appeal information is obtained for future use
What does an appeal status of PREP mean?
Claim has been denied and a call is needed to gather missing appeal information
What does an appeal status of DRAFT mean?
Claim has been denied and all required appeal information is available
What does an appeal status of SENT mean?
The draft appeal work list is automatically completed; an appeal snapshot journal entry is created; the follow-up timer starts
What determines the number of levels an appeal will be pursued?
Client authorization
What are the reasons an appeal may move to external review?
Experimental & Investigational
Unproven Services
Not Medically Necessary
How many levels of appeals are available with Medicare?
Five; three are typically pursued