Claims

Front

What is a claim in healthcare?

Back

A claim is a request for payment that a healthcare provider submits to an insurance company for services rendered to a patient.

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What does it mean to verify a claim?

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Verifying a claim involves checking the details of the claim against the insurance policy to ensure it is valid and eligible for payment.

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What is a Promised Action in claims processing?

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A Promised Action is a documented commitment to take a specific action, such as calling back a provider or member regarding a claim.

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What is the purpose of denial codes?

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Denial codes are used to explain why a claim was denied, providing specific reasons that can help in resolving the issue.

Front

What does the denial code R12520 indicate?

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R12520 indicates that the claim was denied because it is not a covered benefit or service.

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What should you do if a claim is deleted?

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If a claim is deleted, you should verify the benefits for the member before taking further action.

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What is the role of FileNet/WCF in claims processing?

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FileNet/WCF is a system used to manage and store claims information, including verifying the status of claims.

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What action should be taken for an HMO member whose claim is denied for no authorization?

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You should call PMG to verify the status of the authorization for the claim.

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What is the significance of timely filing in claims?

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Timely filing refers to the requirement that claims must be submitted within a specific time frame to be eligible for payment.

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What does it mean to send a claim for rekey?

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Sending a claim for rekey means submitting the claim again for processing, often due to errors in the original submission.