GNMS: Wk4_Day3_AM Review

Put the following Member Claim Inquiry Process Flow into the correct order.

• Member calls BCBS

• Member reviews EOB and has questions

• Claim is processed and EOB sent to member

• Member receives services

• Provider submits the claim

When resolving copay claim inquiries, what two key tasks do you need to complete? Choose the two that apply.

• Determine if a check was sent to the provider

• Review for appeals on the claim

• Review the claim

• Verify the claim was processed correctly

To begin our claim research, we start in (a)   .

• ACE
• Claims GUI
• MPUI
• Emulators

ACE and Claims GUI provide the deductible amount for a claim differently.

• True

• False

To find the actual total deductible amount in Claims GUI, you need to . . .

• Review the Accumulation Tab in Claims GUI

• Use the Total Deductible Amount field

• Subtract the Total Applied Deductible Out of Network from the Total Applied Deductible In Network

• Use the Total Copay amount

The ultimate goal for using (a)   is to get the ​ (b)   .

• Benefit Navigator
• Provision ID(s) and Keyword
• Claims GUI
• Provider Category 

In Claims GUI, if the Work Item Type is coded with a UB this means ​the claim was billed as (a)   . If it is coded as CMS 1500 this means the claim was billed as​ (b)   .

• Provider Type: Institutional
• Provider Type: Professional
• Service Type: Office Visit
• Service Type: Office Services