week 2 professional overview

If my member was not active on DOS the claim should be rejected true or false

• true

• false

For new born claims we will always provided them coverage true or false

• true

• false

Pre authorization is needed from provider before services are rendered.

• true

• false

what will tell you if your claim has a service that requires pre-auth?

• procedure code

• edit

• UM pop up

• dx code

If you cannot find auth in UM pop up what other system must you check to find auth (source of truth)

• Member 360

• PLM

• FOB

what do you want to make sure matches on your claim to the auth on file? choose all that applies

• Patient name

• Provider Tax ID

• DOS

• procedure codes

the definition of a referral refers to services rendered at which of the following POS?

• office POS

• Inpatient (hosp) POS

• Outpatient POS

what do we want to make sure we research on a claim before we process? choose all that applies

• provider Info and all codes

• all POP ups and all edits

• DCN pricier and Claims xtend to make sure they match.

• benefits for claim and accumulators

• eligibility of patient

If claims X-tend said line one should only allow 50% of allowable amount, can we change that?

• yes

• no

what are three indicators that you will need to manually Price your claim ( In DCN pricer)

• 1. Pricing edit on the claim

• CX pop will tell you

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

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