Competitive Bid Modifiers

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Competitive Bid Modifiers

Presented by

Noridian Provider Outreach and Education July 2016

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Disclaimer

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the

information contained in this release can be found on the Noridian website and the CMS website.

The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. • Noridian Medicare Website (https://med.noridianmedicare.com) • CMS Website (https://www.cms.gov)

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Workshop Protocol

• Attendee lines are muted upon entry • Questions

– Verbal questions at the conclusion of the material

• Certificate of Completion

– CEUs are not offered for this course • Presentation Handout

– Email: [email protected]

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Asking a Verbal Question

July 2016 Noridian DME Outreach and Education 4

Click on Participants tab at top right Click on Participants tab at top right Click on Hand on bottom right Click on Hand on bottom right Must have a phone as shown Must have a phone as shown

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Acronyms

• CB: Competitive Bid

• CBA: Competitive Bid Area

• CBIC: Competitive Bidding Implementation Contractor • DMEPOS: Durable Medical Equipment, Prosthetics,

Orthotics, and Supplies

• HCPCS: Healthcare Common Procedure Coding System • NF: Nursing Facility

• NMO: National Mail Order • SNF: Skilled Nursing Facility • SPA: Single Payment Amount

• SSA: Social Security Administration

• www.cms.gov/apps/acronyms

Noridian DME Outreach and Education

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Agenda

Competitive Bid KT Modifier KV Modifier J4 Modifier KL Modifier KG, KK, KU,KW Modifiers KE Modifier KY Modifier Additional Modifiers Resources and Reminders

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Modifiers

• Use appropriate HCPCS code and CB modifier in effect during a contract period.

• Inappropriate use will result in denial

• CB modifiers in addition to existing modifier requirements

• www.dmecompetitivebid.com/Palmetto/Cbic.nsf

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Competitive Bid

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Competitive Bid

• Stay Connected • CBIC Listserv • CBIC • 1-877-577-5331 • Palmetto GBA

Competitive Bidding Implementation Contractor 2743 Perimeter Pkwy Ste 200-400

Augusta, GA 30909-6499

• www.dmecompetitivebid.com/palmetto/cbic.nsf/Do csCat/Home

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Find a CBA Tool

1. Beneficiary ZIP code (per SSA)

2. Enter in CBA finder tool

– www.dmecompetitivebid.com

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Find a CBA Tool

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• Rounds

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Find a CBA Tool

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• Product

Product Category Spreadsheet

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KT Modifier

Traveling Beneficiary

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/DME_Travel_Bene_Factsheet_ICN904484. pdf

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KT Modifier

• Non-mail-order DMEPOS items

• Traveling beneficiary

– CBA travels to Non CBA – CBA travels to CBA

• SNFs and NFs (noncontract)

– Located in non CBA – Enteral Nutrition

– Resident with permanent address in CBA

• Payment is always based on the beneficiary’s

permanent residence

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Traveling Beneficiary

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Beneficiary Permanently Resides

Within a CBA

Scenario 1

• Nell lives in Charlotte, NC (CBA) • Travels to Miami, FL (CBA) • Nell falls and needs a walker. • Nell must obtain the walker from a

contract supplier for Miami, FL, and the supplier must affix the KT modifier to the claim.

• The contract supplier will be paid the SPA for the CBA where Nell permanently resides. The contract supplier must accept assignment on the claim for the bid item.

• If Nell needs a non-bid item, she may obtain the item from any Medicare-enrolled supplier, which will be paid the fee schedule amount for the area in which the beneficiary permanently resides.

Scenario 2

• Nell lives in Charlotte, NC (CBA) • Travels to Nome, AK, (non-CBA) • Nell falls and needs a walker, which is a

bid item in her home CBA.

• She may obtain the walker from any Medicare-enrolled supplier, and the supplier must affix the KT modifier to the claim.

• The supplier will be paid the SPA for the CBA where the Nell permanently resides. The supplier must accept assignment on the claim for the bid item.

• If the Nell needs a non-bid item for the area she is visiting, he or she may obtain the item from any Medicare-enrolled supplier, which will be paid the fee schedule amount.

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Beneficiary Permanently Resides

Outside a CBA

Scenario 1

• John lives in Butte, MT (Non-CBA) • John travels to Las Vegas, NV (CBA) • John needs a new mask for his CPAP • He must obtain the mask from a

contract supplier for Las Vegas, NV. • The contract supplier will be paid the

fee schedule amount for the state where the beneficiary permanently resides. The contract supplier must accept assignment on the claim for the bid item.

• If the beneficiary needs a non-bid item, he or she may obtain the item from any Medicare-enrolled supplier, who will be paid the fee schedule amount.

Scenario 2

• Bill lives in Bismarck, ND (Non-CBA) • Bill travels to Pierre, SD (Non-CBA) • Bill needs a new mask for his CPAP. • He may obtain the mask from any

Medicare-enrolled supplier. • The supplier will be paid the fee

schedule amount for the state where the beneficiary permanently resides.

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KV Modifier

Furnished as Part of a Professional Service

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/DME_Physicians_Other_Pract_Factsheet_I CN900926.pdf

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KV Modifier

• Item furnished by physician or other treating practitioner

(noncontract suppliers)

- Walkers

- Folding Manual Wheelchairs - External Infusion Pumps

• Beneficiaries permanently residing in CBA • Not to be used by contract suppliers in a CBA • Billed to DME MAC using physician’s DMEPOS

number

• Billed on same DOS as professional service Paid SPA

• “Physician” = Physician, NP, PA, and CNS

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J4 Modifier

Furnished by a Hospital Upon Discharge

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/DMEHospitals_Not_Contract_Suppliers_Factsheet_ ICN905463.pdf

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J4 Modifier

• Item furnished by hospital upon discharge to

its own beneficiaries

– Walkers

– Folding Manual Wheelchairs – External Infusion Pumps

• Not to be used by contract suppliers in a CBA

• Billed to DME MAC using hospital DMEPOS number • Paid SPA

• Hospitals advised to submit hospital stay claim first or same day

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KL Modifier

Mail-Order Diabetic Supplies

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DME_Mail_Order_Factsheet_ICN900924.pdf

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NMO Modifier - KL

• Diabetic testing supplies

• Delivered by any method

• Beneficiary Options

– Delivered directly to their home (Mail-order)

• KL modifier

– Pick up (Non-mail-order/no home delivery)

• No KL modifier

• Payment amount same

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KG, KK, KU, KW Modifiers

Codes Furnished in Multiple Product Categories

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KG, KK, KU, KK Modifier

Resources

• MLN SE1035

– http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1035.pdf

• MLN MM9059

– http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9059.pd f

– Reject as unprocessable claims billed with invalid HCPCS/Modifier combination

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KG & KK Modifiers

• Same supply or accessory furnished in multiple CB product categories, or

• Same code can be used to describe both competitively and non-competitively bid items

• Beneficiary resides in CBA

– Applies to contract, noncontract and grandfathered suppliers

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KG & KK Modifiers Examples

• Example: E0981 (Seat Upholstery) – KG Modifier

• Standard power wheelchair

– KK Modifier

• Complex rehabilitative power wheelchair

• Example: A4636 (Handgrip, Cane, Crutch, Walker)

– KG Modifier

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KG Modifier

• IV Pole used with enteral nutrition

– E0776

• NPWT

– A7000 – A6550

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KU Modifier

• Effective July 1, 2016

– Some accessories used with Group 3 complex rehabilitative power wheelchair bases

• Accessory list MLN SE1614

• Dates of service on or after January 1, 2016 • Billed after July 1, 2016 and before January 1,

2017

• Append KU modifier • Paid at fee schedule

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KU Modifier

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• Some group 3 complex power wheelchair

accessories

– Dates of service on or after January 1, 2016 – Submitted prior to July 1, 2016

– Paid at blended amounts

• Can be reopened

– Request KU modifier added

– Will be adjusted to the fee schedule

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KU Modifier

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• Claims may be reopened via spreadsheet

• Information required

– NPI/PTAN of supplier – Beneficiary full name – HICN

– Date of Service – HCPCS Codes – CCN

– Reason for reopening

• Cover sheet indicating written reopening request to add KU modifier is sufficient

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KW Modifier

• Not authorized for current use

• Not valid for billing for any DMEPOS

codes

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SPA Files

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SPA Files

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Round 2 Recompete

Midwest Region

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KE Modifier

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KE Modifier

• Append to accessory code used with non-competitive bid base unit

• Resources

– MM8181

• http://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/downloads/MM8181.pdf

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KY Modifier

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KY Modifier

• Append to CB wheelchair accessories

– Round 2 or subsequent round – Certain non-CB base units

– Beneficiaries in Round 2 or subsequent rounds CBA

• Append to accessory code

– Used with complex rehabilitative PWC bases

• Not Round 2 (or subsequent Round) • Bid in Round 1

• MLN Matters MM 8181

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Round 2 KE and KY Modifier

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MM8864

• CB wheelchair accessories

– Non-CB wheelchair bases

• “Round 1” – original Round 1

• “Round 2” – Round 2 and subsequent

• Addresses 4 scenarios for accessories

•

http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8

864.pdf

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MM8864 Scenarios

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Additional Modifiers

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Repairs and Replacements

• Repairs

– Any Medicare-enrolled supplier – Modifier RB

• Replacements

– Contract supplier – Modifier RA

• Replacing the entire option or accessory is considered a replacement and subject to CB • Updated fact sheet (April 2016)

– https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNProducts/downloads/DME_Repair_Replacement _Factsheet_ICN905283.pdf

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Repairs and Replacements

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• Replacement of a part to make it

serviceable

– Either a contract supplier or any other Medicare-enrolled supplier

– Parts - components to repair base equipment

• Options and accessories

• Composed of many parts • Replaced entirely

– Not repair – Subject to CB

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• Miscellaneous parts

– K0108 or E1399

– Contractor’s individual consideration of each claim

• Replacement paid at SPA

– CB item – CB base – CBA

• Replacement paid based on individual

consideration by DMEMAC

July 2016 Noridian DME Outreach and Education 50

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Routinely Replaced Items

• Not considered parts

• Must be provided by contract supplier

• Examples (not all inclusive):

– Blood glucose strips – CPAP accessories – Seat cushions

– Enteral nutrition

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Comprehensive Error Rate

Testing (CERT)

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CERT 2015 Improper Payment Rates

www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html

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CERT

• Randomly select submitted claims

• Request medical records from provider/supplier that submitted claim

• Review claims and medical record for compliance with Medicare to include:

– Coverage – Coding – Billing rules

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CERT Error Categories

• Insufficient documentation • No documentation

• Service incorrectly coded

• Medically unnecessary service • Other

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Decrease CERT Errors

• Educate staff

• Train coders/billers

• Submit correct information

– Beneficiary name, social security number, Medicare number, date of service

• Submit legible and complete records

– Dates, required signatures, etc.

• CERT Inquiries

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Resources

• Policies

– LCD/Policy Article

– Documentation Checklists – “Dear Physician” Letters

• Education & Outreach

– Noridian Supplier Manual

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Resources (cont.)

• Acronyms

– CMS Acronym List

(https://www.cms.gov/apps/acronyms/) – Bottom of the Noridian Medicare Website

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New Supplier Education

Curriculum

• General and policy specific

• Short presentations grouped by relevance • Quiz at conclusion

with certificate

• Great for new and existing suppliers

• Suppliers encouraged to view both general and policy specific curriculum • Located on the Noridian Medicare Website – Browse by Topic > Welcome New Supplier

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Denial Code Guidance

• Each denial code webpage includes:

– Claim adjustment reason code and description – Claim adjustment remark code and description – Common reason why Noridian uses that

reason/remark code

– Next step (re-file, redetermination, reopening, etc.) – How to avoid these types of denials

– Applicable resources

• Located on the Noridian Medicare Website

– Browse by Topic > Remittance Advice (RA) > Denial Code Guidance

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PECOS Requirement

• Claims may be denied if:

– The ordering physician is NOT in PECOS

– The ordering physician is not of the specialty to order – If the physician's name submitted on the claim does

not match their name in PECOS

• PECOS Edits located on the Noridian Medicare Website

– Claims and Appeals > Claim Submission > PECOS Edits

• View the PECOS DME on Demand

(http://www.brainshark.com/noridian/vu?pi=zHlz

qyKBpz87uMz0)

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ICD-10 Questions?

• ICD-10 Implementation took place 10/1/15 • ICD-10 Resources

– ICD-10 Webpage located on the Noridian Medicare Website

• Browse by Topic > ICD-10

– CMS ICD-10 Webpage

(https://www.cms.gov/medicare/coding/icd10/index.ht ml)

– “Road to 10” Website (www.roadto10.org)

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ACA (WOPD) 5-Element Order

• Required Elements

• Beneficiary's name

• Item of DME ordered - this may be general – e.g., "hospital bed"– or may be more specific

• Signature of prescribing practitioner

• Prescribing practitioner's National Practitioner Identifier (NPI)

• Date of order

• Currently enforced by DME MACs and CERT • Implemented 7/1/13

• Enforced 1/1/14

• Followed by DWO prior to billing

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Corrections and Amendments to

F2F and 5EO: Prior to Delivery

• Treating physician amend the F2F visit notes or the 5EO following the guidance in the PIM; or

– (Internet-Only Manual, 100-08, Chapter 3, Section 3.3.2.5)

• New F2F examination or new 5EO may be created, whichever is applicable

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Corrections and Amendments to F2F

and 5EO: After Delivery

• Prior to claim submission original supplier may:

– Recover delivered item(s)

– Obtain a compliant 5EO or F2F

– Re-deliver the item(s) to the beneficiary; or

• After claim submission:

– Original supplier recover their item(s)

– New supplier complete the transaction after complying with all requirements

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Email Updates

• Tuesday and Friday • Latest updates and

announcements • Customizable

• Sign-up in the lower right corner of our website

• Click “subscribe”

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Website Survey

• Your feedback is valuable

• Click “Yes, I’ll give feedback”

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Electronic Submission of Medical

Documentation (esMD)

• Transmit documentation electronically for review • Who accepts documentation via esMD?

– DME MAC (Noridian)

• Complex Medical Review and PMD PAR

– CERT

– Recovery Auditor – ZPIC

• CMS esMD Webpage (

www.cms.gov/Research-

Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html?redirect=/esmd)

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MREP

• Medicare Remit Easy Print

– Free software!

– View, search and print remits – Print and export reports

• CMS Brochure (www.cms.gov/MLNProducts/downloads/Medica reRemit_0408.pdf) • MREP Software (www.cms.gov/AccesstoDataApplication/02_Me dicareRemitEasyPrint.asp)

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Medicare Learning Network (MLN)

• Guides • Articles • Educational Tools • Booklets Brochures • Fact Sheets • Training Presentations • Web-Based Training • And more! • MLN Webpage (www.cms.gov/Outrea ch-and- Education/Medicare- Learning-Network-MLN/MLNGenInfo/ind ex.html)

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Noridian Medicare Portal

• Will replace Endeavor

– Same functionality as Endeavor

• Five roles:

– Provider Administrator

• Must register first

– Provider End User – Vendor Administrator – Vendor End User – Dual Role • Noridian Medicare Portal webpage located on the Noridian Medicare Website – Browse by Topic > Noridian Medicare Portal • Login • User Manual • Registration Guide

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We Are Coming To You!

• “Catch the Noridian Express to Medicare Success”

• Half day Sessions • Register online • Located on the

Noridian Medicare Website

– Education and Outreach > Schedule of Events > In-person Seminars

• Fall Seminar locations to be announced later this summer!

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Education Opportunities

• Web-Based Workshops • Q & A Sessions • DME On Demand • Education Request

• Ask the Contractor Teleconference (ACT)

• Education and Outreach Webpage located on the Noridian Medicare Website

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Beneficiary Contact Information

• Beneficiaries who need assistance can be directed to:

– 1-800-Medicare (800-633-4227)

• Question on claims and coverage of equipment

– Social Security Administration (800-722-1213)

• Update name/address, questions on premiums, Medicare entitlement

– Benefits Coordination Recovery Center (800-999-1118)

• Primary insurance information update

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Asking a Verbal Question

• To ask verbal question:

– Click on the Participant tab

• Click on the hand icon

– The telephone

handset or computer headset must be present beside your name

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