FEP Medical Management Job Aid
Job Aid for Non-Covered Health Care Procedure Codes

Purpose: To provide direction to Medical Management associates regarding FEP Non-Covered Health Care Codes

Process:

Locate the Non-Covered Health Care Procedure List

* Log into FEP Direct

* Scroll to the bottom under Support Processing & choose FAM Volume II

* Scroll down under Chapters & Exhibits

* Click on Exhibit 2-Non-Covered Health Care Procedure Codes

OR

* http://bluelink.wellpoint.com/bluelink/Top25Documents.aspx * Click on the Non-Covered Health Care Procedure Codes link

Using the Non-Covered Health Care Procedure List

* At the top of the list click on “Summary of Procedure Codes”

* This will bring up a list of non-covered codes in specific groupings per CPT code. From this list you can choose the grouping your code would be in.
FOR EXAMPLE: You are given CPT code 15839. This code falls between codes 15819-17380…Surgery: Integumentary System. Click on the category name and look through the list for your specific code. 15839 - Excision, excessive skin; other area is listed here as a Non Covered Health Care Procedure Code.

UMRs

WMDS * If all of the codes are found on the non-covered benefit list: * Load the case with the procedure codes * Indicate the non-covered benefit codes in the case note * Send to RN for review * If at least one code is found on the non-covered benefit list: * Load the case with the procedure codes * Indicate the non-covered benefit codes in the case note * Send to RN for review
TRIMED
* If all or at least one code(s) is found on the non-covered benefit list: * Load the case with the procedure codes * Indicate the non-covered benefit codes in the case note * Send to RN for review
UMR Script:

If ALL code(s) are on the non-covered benefit list:
The code(s) you have requested are a non-covered benefit. At this time, I will load a case to generate a letter for you.

If AT LEAST ONE code(s) are on the non-covered benefit list:
For that outpatient service, no Precert is required. Codes ___________ are a non-covered benefit. However, codes ________ are eligible for an optional service called an Advanced Benefit Determination. The turnaround time for a non-urgent request can take up to 15 days and 3 days for a life-threatening urgent review. Is that something you would like to proceed with?

UMR Copy and Paste:

If ALL code(s) are on the non-covered benefit list:

MODE OF REQUEST: * phone call from * VM/Audix Date & Time Received * fax Date & time received DCN# * e-review Date & Time received *e-mail address

What is being requested: ABD Urgent ABD

Eligibility Verified, FEP Primary *per FEP Direct *WMDS *if Medicare/other ins primary- document why you are opening case

Member address verified *per caller/ fax/e-review *per FEP Direct (bad address requires case specific address in WMDS) Member phone #

Diagnosis Code:

Advised Procedure code(s): ------- are a non-covered benefit for the member

Sent Non-Covered Benefit Letter

If AT LEAST ONE code(s) are on the non-covered benefit list:

MODE OF REQUEST: * phone call from * VM/Audix Date & Time Received * fax Date & time received DCN# * e-review Date & Time received *e-mail address

What is being requested: ABD Urgent ABD

Eligibility Verified, FEP Primary *per FEP Direct *WMDS *if Medicare/other ins primary- document why you are opening case

Member address verified *per caller/ fax/e-review *per FEP Direct (bad address requires case specific address in WMDS) Member phone #

Diagnosis Code:
Procedure Code to be reviewed by RN:

Advised code(s) ------- are a non-covered benefit for the member

MD: In network/Out of Network *per streamline, *provider directory, *CS (on electives)
Facility: In network/Out of Network *per streamline, *provider directory, *CS (on electives)

Case forwarded to Nurse for Review.
No Clinical Available (USE ABD/LOI SCRIPTs)

QT UMR for WMDS Free Form Text for Non-Covered Benefit Letter
Purpose: Free Form Text is to be used for situations where specific language is required to be inserted into the body of a letter.
Note: This is a business specific process. The leadership team has determined this process is indicated for this particular letter.
Procedure:
1. For initial loading of a case, leave the case with a status of Pended and a reason of Awaiting RN/Care Manager Review and ADD the case. Immediately go back in the case and use the following steps to complete the process.
For cases that are already loaded, use the following steps to complete the process. 2. Tab 2 a. Change Tab 2 I. Status : Pre-D Not-Certified II. Reason: Non-Covered Service b. Copy the reference number on Tab 2 c. Click Case_Service UDW 3. Click Service UDW 4. Paste the reference number into the green field labeled Service Reference Number and hit the Enter key 5. Click on Tab 4. Letter Options 6. In Tab 4. Letter Options a. Letter Text Type: FFTEXT b. Date Entered: T c. Letter Text OR Document Log Note for MANUAL Letter Processing Option: d. Paste: The procedure code(s) submitted are a non-covered benefit. 7. Add UDW page 8. Add 9. Follow-up on letter by reviewing the FEP Letter Error task list at least once a day

UM RNs

* After you verify the non-covered benefit status, advise provider per phone contact and complete case so both the member and provider will receive the Non-Covered Benefit letter. * If some codes in case are covered benefits, complete case as per normal for those codes & notify provider of review results. Letters will generate for member & provider if case completed correctly.