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Auth, ref EOB

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  • True or False: EOPs go to the Provider
    True: Explanation of Payment
  • What is a CPT code?
    Current Procedural Terminology - a code for a service a provider is placing on an auth/claim
  • True or False: Referrals do not have an end/void date.
    False: Episode of Care: •6 months for ADSM •365 days for Everyone Else
  • When you look in the RADS tool or benefits, if something is Not Covered, does it need an Auth/Referral?
    No, if it is not covered, we do not cover it at all/it may be on the exclusions list.
  • What Reports Eligibility?
    DEERS
  • What is an EOB?
    Explanation of Benefits sent to the member about their visit/breakdown of their doctors visit
  • True Or False: DHA-QL covers LOD claims/Auths/Referrals
    False: DHA- GL as in Defense Health Agency - Great Lakes
  • What is an ICD-10 code?
    Diagnosis code - a code for a symptom or 'diagnosis' a patient had.
  • How many Visits is a Second Opinion referral?
    2 - 1 initial and 1 follow up
  • When you look in the RADS tool or benefits, if something is Limited, does it need an auth/referral?
    Yes. It MAY be covered with an auth/referral if it shows as limited.
  • What is a referral?
    When PCM/provider places a request to send a member to a specialist
  • When you look in the RADS tool or benefits, if something is Covered, does it need an Auth/Referral?
    No. It is covered and does not need any extra steps
  • How many visits is an Evaluate and Treat referral?
    6 - 1 initial visit and 5 follow up visits
  • What is an Authorization?
    when a PCM/Provider places a request to complete a service/provide DME for a member
  • Who determines Eligibility?
    BOS: Branch of Service
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