Claims

What should you advise you 200C member if you have found the claim in content framework and submitted it to be keyed?

• You will receive a letter regarding the claim, however your claim will be processed immediately

• You will receive a letter about the claim discussed today however, we were able to locate the claim and have submitted it for processing. It can take 30-45 days to process

• We were able to locate the claim and have submitted it for processing. It can take 30-45 days to process

• It will be processed in 60 days

Your CA HMO member wants to verify status of claim denied RE000. You have tried to reach the medical group to verify however, you are unable to reach them and you have left a voice mail? What should be your next steps?

• End the procedure

• Create a Promised Action to call back

• Contact the provider directly

• Go to the next step

What is the purpose of verifying the claim image and patient information?

• To ensure provider has correct info and request resubmit.

• To ignore the claim.

• To submit the claim yourself.

• To request a new claim.

What does the denial code R12520 indicate?

• Age/Gender Denials

• Referral Denial

• Not a Covered Benefit or Service

• Timely Filing

What is the denial code used to indicate PMG Liability?

• R24280

• R50110

• R11720

• R24140

What is the reject code for a patient not being an eligible member at the time services were rendered?

• R01030

• R11010

• R11240

• R11312

What system would you verify if a claim is not found in Solution Central?

• FileNet/WCF

• Mainframe

• Call PMG

• Call Provider

If you have discussed multiple claims and one of them is not found, what should you do to correct document your DMHC call?

• Ignore the claim not found

• Tag the other claims and document the claim not found and send the required letter in the Create Correspondence Task

• Create a research task to discuss claims

• Create a second manage claims task to document the claim not found and send the required letter in the exempt grievance task

Claims denied for PMG liability can be sent for adjustment?

• True

• False

What should be done for an HMO member, when their claim is denied for no authorization?

• Ask the member to submit a new claim

• Send the required letter

• Call the Medical Group to verify status of the authorization

• Call the provider to request the status of the authorization