Claims

Front

What is a claim in the context of insurance?

Back

A claim is a formal request made by a policyholder to an insurance company for compensation for a covered loss or event.

Front

What does it mean when a claim is 'processed'?

Back

Processing a claim involves reviewing the submitted information, verifying coverage, and determining the amount to be paid to the policyholder.

Front

What is the typical time frame for processing a claim?

Back

It can take 30-45 days to process a claim.

Front

What is a denial code?

Back

A denial code is a specific code used by insurance companies to indicate the reason a claim was denied.

Front

What denial code indicates PMG Liability?

Back

R50110.

Front

What should you do if an HMO member's claim is denied for no authorization?

Back

Call PMG to verify the status of the authorization.

Front

What system should you check if a claim is deleted?

Back

FileNet/WCF.

Front

What action should be taken if one of multiple discussed claims is not found?

Back

Create a second manage claims task to document the claim not found and send the required letter.

Front

What is the purpose of documenting claims?

Back

Documenting claims helps track the status and history of each claim, ensuring proper follow-up and resolution.

Front

What is the role of PMG in claims processing?

Back

PMG (Provider Management Group) assists in verifying authorizations and managing claims for HMO members.