Tier 3 Review Quiz

Performed when a claim has been previously denied.

• Reprocessed

• Adjustment

• Reversal

• Adjudication

Performed when the member's cost sharing is affected.

• Adjustment

• Reversal

• Reimbursement

• Reprocessed

Performed when the claim has never been applied towards the member's benefits.

• Reversal

• Adversal

• Rewritten

• Reprocessed

Select the steps that will help you locate the claim in question.

• Review Contract Handling

• Locate the correct member policy

• Select the Claim summary link

• Ask for the OI and other info about the claim

What does PARE stand for?

• Pathology, Aneurism, Radioactive and ER Physicians

• Pathology, Anesthesiology, Radiology, ER Physicians

• Pantheologists, Aneurism, Radiology and PCP

What information may be provided to a member when inquiring on the status of a claim?

• Date Paid

• Total Paid

• Claim Denial Reason

• Denied Amount and Receipt date

What are the ways to determine if a claim is in SIU review?

• Pended claim description and CRU Alert

• Adjusted claim and CRU alert

• Adjusted claim and CRM Alert

• Pended claim description and CRM Alert

What should you never do when referring to phone a friend?

• Have the member hold

• Let caller's know PaF is on the line

• Transfer the call

• Hang up the call

What does "IPA" stand for?

• Independant Practice Association

• Independent Physician Association

• Independent Provider Association

• Independent Policy Account

What are some examples of Home Health Care Services?