Overview week one processing

Looking at the DCN below which the claim that was received in DDC (paper claim)

• 23121FB2222

• 23061272222

• 23011BC2222

• 23073BQ2222

True or False you are allowed to change Clinical editing (claim xtend)

• true

• false

when we see the CX pop up what factors do we look for in the claims x-tend editing) choose all that applies

• If CX made any changes to Billed code

• Look at the lines that did not allow

• Look at the support code field

• Any additional lines in Claim x-ten with a history DCN

the pay percentage field in claim x-tend is the allowable amount not co-insurance. True or false

• true

• false

Modifiers can affect claim xten and how it pays the allow amount. It an increase the allowable amount or decrease. True or False

• true

• false

when it comes to negotiate discount for Non-par provider is that negation done by a vendor (MPI) or Us?

• Us

• Vendor

what three factors below will indicate if you need to manually price a claim for a PAR claim.

• 1. Pricing edit on the claim

• 1. Any line allows in full (writeoff field is blank)

• 1. Any line denies in full (writeoff field has the lines charge showing)

• If provider non-par

which below are the correct processing/research steps?

• 1 Research provider info
  2.Research All codes
  3. Check Pop Ups
  4. Check edits
  5. Check Member
  6. Check Benefits
  7. Check accumulators
  Start Processing steps

• 1 Research provider info
  2.Research All codes
  3. Check Pop Ups
  4. Check edits
  5. Check Benefits
  6. Check accumulators
  Start processing steps

• 1 Research provider info
  2.Research All codes
  3. Check Pop Ups
  4. Check edits
  5. Check eligibility
  6. Check Benefits
  7. Check accumulators
  Start processing steps

What three edits below do we want to research/resolve first before all others?

• Eligibility edits

• Duplicate edits

• pricing edits

• Timely Filing edits

What rules below are true when it comes to a claim trying to A-log (auto adjudicate)?

• do not let claims a-log in training

• claim will not let you reject if claim is trying to A-log

• on the floor you can let claim a-log as long as you are not rejecting

• A-log is not important