WorkSmart Institute Administrative Simplification Tools

  

Administrative Simplification Tools : Adoption Matrix

Adoption Matrix

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Posting to the Forum website is not a guarantee of adoption. Please contact the appropriate plan representative regarding any specific questions or concerns. Click here for health plan contact information.

Note: click on a health plan name to view their website.

First Choice Health Administrators Group Health Cooperative Premera Blue Cross Regence Blue Shield Aetna Asuris Northwest Community Health Plan of WA KPS Health Plans Molina Healthcare of WA Pacificare Labor & Industries Health & Recovery Service Administration Uniform Medical Plan Medicare
 Best Practice Recommendations - Electronic Processing
   Usage of Group Codes, Reason Codes, Remark Codes   check check see footnotes check see footnotes     check     check check  
   Electronic Processing of Corrections to Claims   check check see footnotes check see footnotes     check     check see footnotes  
 
 Claims Processing
   1. Submitting Supporting Documentation (w/ Cover Sheet) check check check check check check     check check   check check  
   2. Submitting Corrected Claims (w/ Cover Sheet) check check check check check check     check check   check check  
   3. Following Up on Processed Claims check check check check check check     check check   check check  
   4. Using Common Modifiers check check check check check check     check check   check check  
   5. Coding Anesthesia & Billing CRNA check check check check check check     check check   check check  
   6. Getting Claim Status check check check check check check     check check   check check  
   7. Splitting Claims check check check check check check     check check   check check  
   8. Handling Injury Claims check check check check check check     check check   check check  
   9. Submitting EOB on Electronic Claims check check check check check check     check check   check check  
   10. Resubmitting Claims Electronically check check check check check check     check check   check check  
   11. ER Notes Not Required w/ Claims check check check check check check     check check   check check  
   12. Patient Card Not Required w/ Claims check check check check check check     check check   check check  
   13. Adjustments Made to Paid Claims check check check check check check     check check   check check  
 
 Referrals & Prospective Review
   1. "One-Stop-Shop" Processing Requirements check check see footnotes check check check     check       see footnotes  
   2. Using Standard Referral Actions check check see footnotes check no check     check       see footnotes  
   3. Self Refer for Women's Healthcare check check see footnotes check check check     check       check  
   4. Coding Referrals & Authorizations check check see footnotes check check check     check       see footnotes  
   5. Tolerance Period for Referral Dates check check see footnotes check check check     no       see footnotes  
   6. Referrals Not Required for ER Visits check check see footnotes check check check     check       see footnotes  
   7. Requesting Prospective Clinical-Medical Review check check check check no check     check       check  
 
 Referrals & Prospective Review
   1. Handbook for Practitioner's Staff check check check check check check     check     check check  
   2. Confirmation Receipt of Credentialing Application check no no no no no     check     no no  
   3. Adjudicating Claims as of Effective Date check check check check check check     check     check check  

Footnotes:

check Referrals are never required for any of the health plan's products
checkImplementation date to be determined
checkOnly hospital claims
checkReferrals are never required for any of the health plan's products. Applies only to authorizations.

 


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