CS Member Intensive Claims Assessment

Claims can be rejected because the provider incorrectly submitted the claim. A provider may have billed with inaccurate medical coding, or the claim was not completed.

• TRUE

• FALSE

If a claim shows a Denied status, the charges were denied. It may contain incomplete or inaccurate information. Some claims can be denied if the plan deems the claim medically unnecessary or it's not a covered benefit. In addition, providers may need to resubmit the claim for reconsideration.

• TRUE

• FALSE

Why is it important to keep up-to-date Coordination of Benefits (COB) information on file?

• To ensure accurate records for claim processing

•  To reduce grievances and other escalations

•  To provide a positive experience for our members and providers

•  To maintain quality assurance and corporate compliance

•  All of the above

Which term is NOT a valid claim status?

•  Pending

•  Withdrawn

•  Approved

•  Rejected

•  Denied

A member has questions about a claim for outpatient hospital services. Select the claim form that should be used for these charges.

•  Institutional (UB 04 / CMS 1450)

•  Professional (HCFA 1500 / CMS 1500)

What are TWO reasons a provider might bill a member?

• They’re competing in a bidding war with another insurance company

•  They were unaware the member had insurance coverage

•  Their claim was denied or rejected

•  They raised their fees

Which THREE of the following are NOT considered balance billing issues?

• Copays

•  Provider did not submit a claim

•  Deductibles

•  Coinsurance

A member has questions about the status of a claim. The claim is currently pending and was received 10 days ago. What is the appropriate response to this member?

• Do not send the claim for review. Explain the 30-day processing time, and advise the claim can be sent for review if it is still pending after 30 days.

•  Send the claim for review by selecting Disagree/Dispute and capturing the necessary information.

•  Do not send the claim for review. Inform the member their claim is on its way to being approved and they should not worry.

•  Do not send the claim for review. Direct the member to call Provider Services to learn more about a pending claim.

Balance billing occurs when a member is billed by a provider for more than their cost sharing amount.

• TRUE

• FALSE

Which is NOT an example of balance billing?

• Provider did not submit a claim to the Plan; Member is being billed

•  Provider submitted a claim for the member’s coinsurance amount; Member is being billed

•  Provider submitted a claim but it was denied or rejected; Member is being billed

•  Provider submitted a claim but was paid less than the amount billed; Member is being billed