CRM

ATTACHED CLINICALS VIA MRM CCR HMO Referral Sourcing Nurse

HMO / PAR / Non‐PAL Misroute #WQMisroute / CCR HMO Referral / CRM #: xxx / Claim #: xxx / CPT Codes: xxx / DOS: xxx / Medicare HMO member / Non‐PAL services / PAR provider / No referral required / Routing back to adjuster per Mentor document ‘CO‐Validating Work Item is for HMO Referral/Dual Demo Provider Dispute Team’ /

PCP DRIVEN

#WQMisroute / CCR HMO Referral / CRM #:XXX / Claim #: XXX / CPT Codes: XXX/ DOS: XXX /Medicare HMO member / PCP DRIVEN as per Florida Medicare Market Guide / Routing back to adjuster per Mentor document ‘CO‐Validating Work Item is for HMO Referral/Dual Demo Provider Dispute Team’ /

HOME SOLUTION- HOME HEALTH CODE: #WQMisroute / CCR review for CRM #: xxx / Claim #: xxx / CPT Codes: xxx / DOS: xxx / There is no current approved authorization on file for services / Per Medicare home health map UM overview: Home Solutions NJ county Camden / Market guide does not support CCR review / Returning case to adjustor /

MISROUTE MISSING INFORMATION

#WQMisroute / CCR HMO Referral / CRM #: xxx/ Claim #: N/A / CPT Codes: N/A/ DOS: N/A/ Medicare HMO member / Missing Information / Routing back to adjuster per Mentor document ‘CO‐Validating Work Item is for HMO Referral/Dual Demo Provider Dispute Team’ /

CCR HMO Referral / CRM # xxx / Claim # xxx / CPT Codes xxx / DOS xxx / Existing denied auth # xxx in CGX/ Denial reason " Lack of information still the same Clinical attachment"/ Routing back to adjuster/

UNABLE TO LOAD TO ACCESS THE CRM:

CCR Review / Provider dispute/ Unable to pull up Claim # XXX in CRM which was provided in adjusters note/ Claim needs to be accessible within CRM in order for Provider Dispute to be completed/ Please reconfirm claim # that requires CCR review/ If Claim cannot be loaded into CRM, please attach screen shot of correct claim to CRM Case # XXX / Thank you

---Ambulatory -- #WQMisroute / CCR HMO Referral / CRM #: xxx / Claim #: xxx / CPT Codes: xxx / DOS: xxx / Found Existing Auth on file #: / Non-Par Rendering provider, Par Facility / Ambulatory / Medicare HMO member / Non‐PAL services / No referral required / Routing back to adjuster per Mentor document ‘CO‐Validating Work Item is for HMO Referral/Dual Demo Provider Dispute Team’

Approved authorization already on file Approved / CCR HMO Referral / CRM #: xxx / Claim #: xxx / DOS: xxx / CPT codes: xxx / CGX authorization: xxx approved / There is a valid authorization on file approved for this service / No further action required from CCR HMO referral at this time / Returning case to adjustor per process document ‘CO‐Determining if an Existing Authorization Can be Used’ /

MODIFIER 26

Approved / CCR HMO Referral / CRM #: XXX / Claim #: XXX / DOS: XXX / CPT codes: XXX / CGX authorization: XXX approved / No further action required from CCR HMO referral at this time because the provider billing with a Modifier 26. / Returning case to adjustor per process document ‘CO‐Determining if an Existing Authorization Can be Used’ /

THE RADIOLOGIST'S NAME: LEXINGTON RADIOLOGY ASSOCIATES LLC, NPI: 1063095628 TAX I. D: 862189482 ON CLAIMS NOTE BECAUSE the provider billing with a Modifier 26.

EPISODIC CPT CODE: G0299

Approved / CCR HMO Referral / CRM #: xxx/ Claim #: xxx / DOS: xxx / CPT codes: xxx / CGX authorization: xxx approved / There is a valid authorization on file approved for this service / No further action required from CCR HMO referral at this time / Returning case to adjustor per process document ‘CO‐Determining if an Existing Authorization Can be Used’ / NOTE: provider information in claim image, NPI no. 1164811550 Name: MOUNTAIN HOME HEALTH SERVICES, LLC, with the same TIN ID: 352503360

CREATE APPROVE AUTH Created and approved an Auth for the code XXX, no existing auth on file. Approved per mentor document "CO-Validating Work Item is for HMO Referral or Medicaid/Dual Demo Provider Dispute Team."

Approved / CCR HMO Referral / CRM #: XXX/ Claim #: XXX/ DOS: xxx / CPT codes: XXX/ CGX authorization: xxx approved / No further action required from CCR HMO referral at this time / Returning case to adjustor per process document ‘CO‐Determining if an Existing Authorization Can be Used’ /

ATTACHED CLINICALS VIA MRM CCR HMO Referral Sourcing Nurse

Approved CPT code per CO-Validating Work Item is for HMO Referral or Medicaid/Dual Demo Provider Dispute Team / Pending Medicare PAL for clinical review PAL code: xxx / Edit: Build an Auth and Attached Clinicals/ Pending / CRM #: xxx / Claim #: xxx / DOS: xxx / CCR Review / Per MG provider can request / Pended to HMO referral nurse for review of Medicare PAL code(s) / CGX authorization #: xxx /

Build an Auth, Attached clinical file FAX TEAM CLINICALS Pending Medicare NON PAR provider for clinical review Non‐PAR provider / CPT: xxx / Edit: xxx / Pending / CRM #: xxx / Claim #: xxx / DOS: xxx / CCR Review / Per MG provider can request / Pended to HMO referral nurse for review of non‐PAR provider / CGX authorization #: xxx /

CCR HMO Referral Sourcing Nurse Provider is disputing on the denial and expecting to reprocess. Denial code: EX:40Z. Attached clinical file PAL code: xxx / Edit: xxx / Pending: / CRM #: xxx / Claim #: xxx / DOS: xxx / CCR Review: / Per MG provider can request: / Pended to HMO referral nurse for review of commercial PAL code(s) per workflow direction: / Confirmed contract opens in CRM: / CGX authorization #: xxx /

UNABLE TO PULL CLAIM # CCR Review / Provider dispute/ Unable to pull up Claim # in CRM which was provided in adjusters note/ Claim needs to be accessible within CRM in order for Provider Dispute to be completed/ Please reconfirm claim # that requires CCR review/ If Claim cannot be loaded into CRM please attach screen shot of correct claim to CRM Case # xxx / Thank you

Pending Commercial PAL for clinical review PAL code: xxx / Edit: xxx / Pending: / CRM #: xxx / Claim #: xxx / DOS: xxx / CCR Review: / Per MG provider can request: / Pended to HMO referral nurse for review of commercial PAL code(s) per workflow direction: / Confirmed contract opens in CRM: / CGX authorization #: xxx Illinois IPA Misroute (can modify for any MG direction that does not allow CCR review) #WQMisroute / CCR review for CRM #: xxx / Claim #: xxx / CPT Codes: xxx / DOS: xxx / There is no current approved authorization on file for services / Per the Illinois IPA Reference Guide for grouper: xxx, only the IPA can request authorization for these services / Market guide does not support CCR review / Returning case to adjustor /