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WorksheetsTier2
Total questions: 20
Worksheet time: 10mins
Off-Exchange member on 3/4/2019 wants to cancel, what is the PTD
03/01/2019
03/04/2019
03/31/2019
04/01/2019
How do you handle the inquiry to resolve cancellation for the member?
Send to an Operations Expert to cancel the plan
Send to Enrollment & Billing (E&B) to cancel the plan
Transfer to a Health Plan Advisor (HPA) to try to retain the member
Cancel the plan for the member
Off-Exchange member wants his plan reinstated after his grievance is approved. You collect an un-validated payment, What is the next step?
Reinstate the member is ISG
Send a service request through Solution Central to E&B to reinstate the member
Transfer the member to a Health Plan Advisor to be reinstated
While researching in ISG, you find that a member has unprocessed cash. How do you handle unprocessed cash?
Apply the unprocessed cash in ISG
Send a request to E&B using ISG
Apply the unprocessed cash in Solution Central
Send a request to E&B using Solution Central
A Certificate of Authority is a form indication that the signer is ___________.
The executor of the member's will
The spouse of the deceased
Any person named in the wil
How many days within the birth of a child must a member notify Anthem to have the baby added to the plan with no interruption in coverage?
31 days
31 + 5 days
60 days
61 days
What would be the effective date of coverage for a baby, born February 2nd?
02/01/2019
02/02/2019
03/01/2019
03/11/2019
What step would you take to add a newborn?
Transfer the call to the state's exchange.
Transfer the call to a Health Plan Advisor (HPA)
Create a service request in Solution Central.
W
Which states have MORE THAN 31 DAYS to add a newborn to a legacy policy?
Colorado, Georgia and Nevada
Connecticut, New York and Wisconsin
Indiana and Ohio
Illinois and Missouri
Using the Lookup Code function in Solution Central what type of visit is 99283
Urgent Care
Preventive Care
Office Visit
Emergency Room Visit
When researching a rejected claim, you can find detailed information by looking at the reason codes which are listed in the _____section of the claim.
Claim Details
Processing Details
Line Details
Which ONE of the following pieces of information is NOT required to price a service?
Procedure code
Units (how many) and amount (cost)
Tax id of provider
Zip code
Patient's gender and age
After you have estimated a pre-service cost for a CA member in the Standalone Pricer, what is your next step?
Provide the quote to the member and close the task in Solution Central
Call the OE Support Desk for verification
Go to the NetworxPricing Tool to run the quote again
Send a DORF letter to the member
When using the NetworX Pricing Tool, type_______ and the contract code in the Schedule Code field.
CAFI
CAPI
GAFI
GAPI
What is the money called that Anthem pays per member to a medical group, regardless of whether or not a member uses medical services?
Premium Billing
Reimbursement Funding
Capitation
Disbursement Allocation
What does it mean when a claim rejects for PMG Liability?
The Primary Medical Group did NOT submit the claim correctly.
The Primary Medical Group submitted the claim twice.
The Primary Medical Group is responsible for the claim.
This service is outside of the capitation agreement with the PMG and Anthem.
a Tier 1 associate transfers a call about a claim that rejected as R00000.
Look at the rejected action Code and its definition
Create a service request to request an adjustment
Call the doctor's office to discuss the claim
Review other claims to see if any has also been rejected
A member calls to inquire as to why her claim was NOT paid at 100%. What is one of the first things an associate should do when part of a service is coded as non-preventive on a claim?
Send the claim for adjustment
check the accuracy of the coding with the provider's office
Send to an OE for pre-approval
Transfer to the claims department
Which type of policy does the CA AB2470 process apply to regarding CA Grievance and Appeals?
Large Group
Small Group
Individual
Large Group and Small Group
The member is dissatisfied with his care and treatment at the hospital last month he feels his issues should have been found and addressed. You select the Grievance and Appeals Task in Solution Central. Which option best fits this situation?
Complete an expedited/urgent appeal
complete a standard appeal
complete a clinical appeal
complete a clinical grievance
