MEDICAL CLAIMS POST TRAINING ASSESSMENT

What is a medical claim?

• A legal complaint

• A request for refund

• A bill submitted to an insurance company for healthcare services

• A prescription from a doctor

What must be checked in vehicular accident-related claims?

• License number

• Vaccination record

• Medical history

• Police or incident report

Claims processing should be completed within 30 working days from receipt of all required documents.

• TRUE

• FALSE

Which of these conditions is gender-specific?

• Migraine

• Pregnancy Uterine

• Scoliosis

• Cataract

A claim was submitted for a dependent named "Juan Dela Cruz" under two different companies. One ID shows him as the principal under Company A, and the other as a dependent under Company B.

What should you do to ensure you encode data correctly?

• Ask the member to decide

• Encode both claims under Company A

• Choose the most recent claim

• Use additional info like Policy No. and ID No. to verify the correct member

A member submits a claim for a urinary tract infection during her 27th week of pregnancy. She has no pre-existing condition coverage but does have maternity coverage.

How should this claim be processed?

• Reject the claim due to lack of pre-existing coverage

• Process under maternity coverage as a complication of pregnancy

• Process under dreaded disease

• Tag as medical collectible

Mr. A availed of benefits within the valid coverage period. However, a few days later, his membership status was updated to “Cancelled.” Since the availment occurred while he was still active, is this considered valid for claims processing?

• TRUE

• FALSE

What kind of condition is Indirect Inguinal Hernia?

• Maternal

• Congenital

• Dreaded

• Pre-existing

Pre-existing conditions must be:

• Covered only if explicitly stated in the Schedule of Benefits

• Always covered by default

• Reported to the Finance Department

• Ignored in claims processing

Which of the following is not a required document for claims submission?

• Operative Technique

• Discharge Summary

• Itemized Statement of Account

• Hospital Fire Exit Plan