Job Application Questions - Essay Example

Dear The only thing I could not improve on your paper was the use of acronyms. You do not explain the meaning of HAC, CHAMPVA, etc. If you are sure your reader understands these acronyms, then you are fine. If they don’t know these terms, then your writing will be confusing. Question 1 In my current position at the HAC as a Customer Service Representative (CSR), I use and interpret the CHAMPVA policy manual, CSC desk procedures, and CPD desk procedures to provide benefits and eligibility information to providers, sponsors and beneficiaries. The CHAMPVA policy manual and the desk procedures help to explain legal provisions, regulations, and benefits covered by CHAMPVA. I respond to daily inquires by telephone and in written correspondence. Most of this communication explains why a claim was denied. To appropriately identify whether a claim was denied in error I reference CPD/CSC desk procedures to research each denial. For instance, if a claim was denied for a code196, surgery not authorized in ASC, I reference the CPD/CSC desk procedures to research whether the code is found in Tricare’s ASC list and in Medicare’s list. I then use the X-code job aide to verify the correct code was used to process the claim. The CHAMPVA policies and regulations are designed to outline the Code of Federal Regulations (CFR). Medicare, Tricare, and CHAMPVA follow rules and regulations listed in the CFR. CHAMPVA follows Tricare’s policy, guidelines, and allowable rates. As a CSR it is important for me to cite various federal codes to providers, sponsors, and beneficiaries. This is especially true when it comes to timely filing, allowable rates, and cost sharing given that these are the areas that are most often appealed. For instance, the Code of Federal Regulations (38 CFR 17.275) outlines a claim filing deadline. With CHAMPVA it is one year from date of service (DOS) for outpatient services but for inpatient services it is one year from discharge date. In the case of retroactive approval, it is 180 days following beneficiary notification of authorization. In the 38 CFR 17.276 outline the appeal and review process for CHAMPVA for claim denials, providers and beneficiaries have one year from denial date to submit an appeal, and 90 days to submit a second level appeal after the initial appeal denial. I use EncoderPro for Internet sufficient research to evaluate sources and appropriately analyze information. To properly answer calls on whether a benefit is covered, using EncoderPro helps me navigate the CHAMPVA policy manual to find the procedure code (CPT). It also helps with providing a description of the code, when the code first was introduced, and different modifiers that can be used with the code. EncoderPro also helps to determine if a claim was denied correctly. In addition to my current position, my Active Duty and Air National Guard experience with the Air Force requires me to reference information using agency manuals, reference systems, and Internet sufficient research to evaluate sources and analyze information. On Active Duty I reference and use Air Force instructions to establish training requirements for my unit that are necessary to meet unit requirements and deployment requirements. All Air Force policies and guidelines are outlined under various Air Force instructions that are found in www.e-publishing.af.mil. As a Personnelist, on a monthly basis I deal with reenlistment, bonuses, retirements, and medical benefits for Tricare eligibility. I need to be aware of current directives for bonuses. When giving medical benefits information to retirees or those going to or returning from a deployment, I need to be familiar with Tricare’s eligibility requirements by referencing their agency manuals and directives. Question 2 Receiving training in CPD (5 weeks) and CSC (6 weeks), and working as a CSR, I am very familiar with medical terminology, coding, and claims processing to appropriately adjudicate appeal requests. The most common appeals concern timely filing and allowable amount (CMAC rates). When working correspondence or assigning a PCDUO request for RU to resolve a timely filing denial, I need to consider when a claim initially was received by CHAMPVA by referencing the Julian date in a PDI and the initial denial date. A claim can be reprocessed or resubmitted one year from the denial date. For new beneficiaries, there is a grace period of 180 days. I also need to research if HAC made an error processing a claim by inputting the incorrect date of service. If the primary insurance (for instance Medicare) processed a claim in an untimely manner, the provider would need to submit an appeal with proof of timely filing to PMD for reconsideration. I am also very knowledgeable with the CHAMPVA allowable for outpatient and inpatient services. I understand when a claim pays Diagnosis Related Group (DRG) or Cost-to-Chare (CTC). Inpatient medical claims should be processed using the DRG except for the State of Maryland and Sole Community Hospitals. When providers submit a corrected claim for inpatient medical claims, changing the billed amount only, they often call requesting an appeal of the allowable. In this situation I would explain verbally or in writing (working correspondence) that the inpatient medical billed amount does not affect the payment amount, but a change in the diagnosis codes will change the payment amount. Another allowable appeals concern I address is for Ambulatory Surgery Center (ASC) claims. ASC claims are processed as outpatient for place of service and not as ASC. This usually lowers the CHAMPVA allowable because the surgery code is paid at the CMAC rate and not the ASC rate. Skilled Nursing Facility and Rug Rates are some of the medical terms I use daily to give benefits information. The CHAMPVA allowable is calculated for Rug Rates is the same as Medicare’s. Custodial care is not covered under Skilled Nursing because it is not deemed medically necessary. Other medical terms I explain to providers, sponsors, and beneficiaries are Certificate of Medical Necessity (CMN) and clinical review. CMNs and medical documents are requested by my QMD-quality assurance queue (nurses), to determine medical necessity. When claims are sent for clinical review, the CHAMVPA nurses to determine if the procedure justifies the level of care review them. I have addressed claims that have been denied because the procedure was not integral to the major procedure. This denial could be appealed through PMD with supporting documents or submitted as a corrected claim. My training in CPD has taught me coding and claims processing. I am familiar with modifiers and how they effect payment. There are six modifiers that will affect payment. If a facility submits a procedure code without using the TC modifier, the procedure code will pay the full CMAC rate for that code, and no additional payment will be made. When the same code is submitted for the professional fees, a correct duplicate denial will result. Understanding preauthorization denials are important for claims processing and the adjudication of appeals. Hospice, Dental, Transplant, and DME over $20000 are preauthorized by HAC. Question 3 I have received training from the Air Force on personal computer use in all Microsoft Office applications and hardware repair. I attended and successfully completed college courses to receive additional training on Microsoft Word, Excel, Access and Power Point. I am skilled in designing Excel and Access applications. I have designed various Excel spreadsheets and programs for my past and current unit with the Air National Guard to help track accountability, training, budgets, reenlistments, and deployment equipment. I use an Access based program in my unit that lists and tracks all members in the Wyoming Air National Guard that includes member’s name, unit, home address, rank, skill level and a list of all training completed. It’s a complex program that provides information on a single individual or unit. Special training was required to learn the Access program called Unit Data. I use a multitude of applications and programs for the Air Force to include DEERS, RAPIDS station and MILPDS to produce ID cards, add Tricare benefits and to update unit and individual information. I also have knowledge of vMPF and Air Force Portal, which is web, based programs that allow users to maintain personal records like awards and decorations, education, track assignments and ancillary training. The MILPDS program that I use allows me to export/import files to Excel and Access spread sheets. I also have experience with various programs and applications used at HAC such as VISTA (AP, VOIS, ICQ, CT/CR, DMD, RDI, ZIP, FMS, VV), PDI Live, and STELLENT. There are various applications in VISTA that I am very familiar with. I use AP to retrieve beneficiaries eligibility information (effective and term date), make changes to mailing addresses and phone numbers, lookup sponsor and beneficiary comments, access comments listed in ROC which is used for preauthorization and appeal determination, and to verify the 180 GP date. VOIS provides other health insurance information on a beneficiary whether CHAMPVA is primary, secondary, or tertiary provider. RDI is used to verify prescription NDC codes and payment amounts. ZIP gives CMAC rates if available based on DOS and zip code. ICQ is used to look up the claims history and to give cost sharing information if the beneficiary’s $50 deductible or $100 family deductible has been met. On a daily basis I use Internet based applications like Encoder to look up procedure codes and modifiers to get the description and meaning of each code. I have access to and use the federal debt offset website to determine if a payment to a vendor (provider) was offset by a federal agency. By inputting the vendors tax ID, the website provides the amount of the offset, name and phone number of the agency, and the date of the offset. Another web-based application I use in the HAC is the NPI Registry. This is used to look up the individual NPI for our vendors. This is primarily used for “not an authorized vendor” and 111 denials on claims. These claims occur when the provider’s credentials are not present for mental health (90801/90802) or other services. This is one reason the claim may register a “not an authorized vendor” coding. If we are able to verify the vendor’s credentials (MD, PhD, DO, etc) in the NPI registry then the claim be reprocessed for payment. Question 4 In my current position as a Customer Service Representative, I take 70 plus calls per day giving information to providers, sponsors and beneficiaries on benefits, eligibility and claim inquiries. The information I provide is always accurate and professional. I have maintained a call quality of 99.99 % without a failed call. To obtain information that is needed to respond to inquiries, I have found that asking the right questions is important. For example, when someone calls to obtain information about their disability status, I know I must ask questions to determine what they currently understand their disability status to be. I provide benefits information to providers, sponsors and beneficiaries on covered and non-covered benefits. I ask what benefit they are inquiring, which procedure code(s) and diagnosis code(s) will be used, then I review the CHAMPVA policy manual and give the exclusions for the procedures. I advise all parties that all claims are based on medical necessity and are subject to clinical review where the medical documents justify the level of care, show medical necessity, and are not experimental in nature. As a CSR I explain to providers the CHAMPVA allowable payment and what they should expect if there is Other Health Insurance. In some instances, providers will bill our beneficiaries when Other Health Insurance (OHI) is present and CHAMPVA has paid our allowable amount. I conduct a courtesy call to the providers ensuring that they understand CHAMPVA’s EOB remark codes and they understand our allowable amount is considered payment in full, and beneficiaries cannot be billed beyond our allowed amount. If the provider needs further clarification, I refer them to the CHAMPVA policy manual Chapter 3, section 4.1. I have verbally provided to providers, sponsors, and beneficiaries various denial reasons and reasons for allowance or disallowance. For instance if a claim denied for missing an OHI EOB, I would verify with the provider whether they are aware the beneficiary has a primary insurance and that corrective actions were needed to adjudicate the claim for payment. There are some denials that are CHAMPVA errors. When this happens it is important that I verbally communicate to providers how CHAMPVA claims processing is established. I also need to be clear with my communication when telling providers about additional paperwork they need to submit for claims concerning some services such as physical therapy. If I do not communicate this information clearly, then claims will be denied and the whole process will move more slowly. My ability to verbally communicate to obtain information, to respond to inquires and provide information and technical guidance was tested recently as part of my military service. I was TDY to Mountain Home AFB for four months as a team leader to assist the unit who had lost 22 members to a deployment. I was also to help the unit prepare for a UCI inspection in which they scored satisfactory in their previous inspection. My role as team leader was to communicate orally with my team members to understand their daily operations, reasons for low customer service satisfaction, and areas they failed and performed poorly in the previous inspection. I provided verbal technical guidance on how to properly establish a file plan online using our local networks; building a continuity folder; establishing new hours to assist our customers in promotions, reenlistments, passport issues, DEERS update, and issuing ID cards. My guidance, training, and technical advice given to the commander, staff members and supervisors enabled them to achieve an outstanding in their Unit Compliance Inspection. Customer service satisfaction increased as well. Read More