OBH Facets Physician Claim Checklist Quick Reference
| Original Effective Date | 12/04/2012 |
|---|---|
| Revision Date | 10/23/2024 |
Instructions
This physician claim checklist is mandatory for adjustments/resubmissions and may also apply for group-specific accounts and related workflow warning messages.
Physician Claim Checklist
Mandatory for every physician claim:
- Pull and view claim image in DOC360; confirm provider per OBH Facets Provider Selection Guidelines P&P.
Mandatory for adjustment/resubmission:
- Subscriber ID
- Member Name
- Receive Date (Julian Date) — Facets defaults to current date; change if invalid.
Receive date logic:
- Fax date earlier than FLN (Julian) on image → use fax date.
- PHS (e.g. PHS-CA) receive date earlier than FLN → use PHS date.
- Providence Health Plan: use BHT04 Transaction Set Creation Date (e.g. 20240603).
- Enter claim note when Optum received date (fax) conflicts with set date.
- If Julian, Fax, or Stamp date < Transaction Set Creation date → contact lead.
- COB (spouse or child)
- Provider ID (TIN matches auth)
- Diagnosis · Authorization · Type of Service
- Statement Covers Period (To & From) · Type of Bill · Payee (Assignment of Benefits)
- Line Items Dates · Accommodation Rates · Line Charges · Units · Billed amount
- Copay · Coinsurance · Deductible · Paid Amount · EOB Codes · Received Date (Julian)
Note for Adjusters: When adjusting prior-year claims where received date was changed on Indicative, restore original received date so processing follows current guidelines.
Recommended — check in Benefits
- Daily Benefits · Tiered Copays · Percentage of Payment
- Non-Notification Penalty · Regular Penalty · Interest Clean Date
- Out of Pocket · Annual Maximum Benefit · Lifetime Maximum Benefit
Notes
- Research Line, eAccomm and Facets before sending Rate Issue.
- RTUE — Participating (INN) & Enterprise Now Ticket for OON; accommodations → Team Lead.
- CBS Medical Necessity (Yes/No) is for Clinical staff, not Claims.
- Parity in CBS does not automatically mean PRR/CCR WFWM applies.
- CCR WFWM → OBH Facets CCR Review; PRR WFWM → OBH Facets Parity Retro-Review (PRR) Process.
Code Descriptions and Terminology
| Code Descriptions | EOB Codes List · Medicare Reason Codes · UM Service Group Code Glossary |
|---|---|
| Terminology | Optum Glossary of Terms, Abbreviations and Acronyms |
Revision History
| Date Published | Section | Revision Details | Writer | Approver |
|---|---|---|---|---|
| 10/23/24 | Physician Claim Checklist | KMR 6123 Under Mandatory items | A.Malkia | Diana G Abbott |
Business Details
| Platforms | Facets |
|---|---|
| Audience(s) | Auditor · Processor · Adjuster |
| State/DIV(s) | All |
| LOB(s) | Commercial · Medicare · Medicaid |
| Product(s) | OBH |
| Documentation Contact | Knowledge Management Request Form |