Quality Tool

What is the purpose of the Quality Tool?

• To log Appeal data

• To log Quality Audit results

Type of Audits include:

• Production, Training, Targeted, Auto Adjudication, Appeal Process, Appeal Entry and Appeal Letter Review

• Training, Production, and Appeals

• Targeted, Auto Adjudication, and Appeals

• Appeal Letters, Appeal Entry and Appeal process

What is the Feedback field for in the Quality Tool?

• If a financial error is found

• For targeted audits only

• Supervisor use when an error is detected

• For internal audits

What error deducts the most points?

• Not Following the Desktop Workflow

• Incorrect Member

• Notes, Documentation

When are audit notes needed?

When NO financial error is found, what will be entered in the Paid Incorrectly field?

When documenting a note in the Quality Tool, what information is needed?

What member information is verified to ensure a correct match?

• Name, DOB, Gender & Member ID

• Member ID, DOB and Name

How many points are deducted when an error is found for incorrect Member or incorrect Provider Vendor?

• 20

• 10

• 50

• 15

If a claim paid $20 for services that should have paid $80, what would be the financial accuracy?

• 40

• 4

• 14

• 400