If the practitioner is not registered in PRM.
The cpt code does not match the authorization.
The procedure is not billable under that practitioner’s discipline.
The associated date is outside the effective date.
The procedure was provided before the date of the license effective date in NPPES and PRM.
Gender and or date of birth is mismatched.
Lack of a financial eligibility guarantor established for the client in Ibhis / Avatar.
The practitioner is not associated with the provider.
The practitioner has not updated their primary provider in PRM.
The practitioner’s taxonomy/credentials have not been updated in PRM.
There has not been an actual episode established for that procedure on that date.
A practitioner/provider has billed a non-Medi-Cal procedure to a Medi-Cal p-auth or vice versa.
Other items to consider:
Red flag – check to see if the practitioner has a license end date that is conflicting with the date of service for the procedure.
The cpt code does not match the authorization.
The effective date should match the associate date.
The registration date is the start date of the practitioner’s record in Ibhis/Avatar and PRM.
The effective start date is the start date of the practitioner for that particular provider.
It is important to take note of the date that the service/procedure was delivered. Make sure that the date of service falls within the financial eligibility coverage dates, as well as license effective dates of the practitioner.