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WorksheetsC3 New Hire - G&A and Claims
Total questions: 21
Worksheet time: 11mins
What type of claim form does a hospital use for billing?
CMS (HCFA) 1500
UB04 (UB92)
Hospice
Skilled Nursing
Using Solution Central Training and Look up codes, what i the definition of modifier 80?
Assistant Surgeon
Bilateral Procedure
Anesthesia 90 min
Procedure performed on right side of body
What type of claim uses Revenue Codes?
UB04 (UB92) Claim
Member Claim
CMS (HCFA) 1500 Claim
Physical Therapy Claim
J10.01 is an example of a ____________ code.
Diagnosis
Revenue
Modifier
Procedure
Using Solution Central Training Environment and procedure code 10021, what was the procedure performed?
Fine Needle aspiration surgical procedure
Spinal manipulation procedure
Rhinoplasty procedure
Spinal manipulation procedure
How do you search for a claim in Solution Central?
Select Manage Claims in the Member column on the Add Task(s) menu.
Select Search Claims on the Home Page
Select Export Claims Search Details
Select the EOB Page
From your search results in the Solution Central claims task, what would you click on to get more details of the claim?
Click the Claim Number
Click the Date of Service
Click the Claim Type
Click the Paid Amount
Which system allows you to view the image of a claim?
Mainframe
Pulse
WCF/Filenet
MAS Toolbar
How will a member know the outcome of their appeal?
They will receive a letter in 5-7 days after the determination is made
They will be transferred to the Grievance and Appeals unit
They will be told to call back next week to check on the status
In Solution Central, how would you send a claim for an adjustment?
In the perform next action drop down arrow, click "requires adjustment"
Go to Accumulator Review page and send to an OE
Go to Explanation of Benefits Review page and start a new task
Which record is sent from the Host Plan to the Home Plan that contains all of the claim information billed from the provider?
SF
DF
RF
WF
Which Primacy rule applies for children when there is no court decree for divorced parents who share custody and both parents have active coverage?
Gender Rule
Active Rule
Default Rule
Birthday Rule
Based on Procedure Code 90688 & Diagnosis Code Z23, would a service billed with those codes be considered preventive or diagnostic?
Preventive
Diagnostic
For a rejected claim, what would 'RDUP' mean as an action code in Solution Central?
Timely Filing
Duplicate
No Eligibility
Non-Covered
If a claim is adjusted and paid in full by Anthem and the member paid the provider directly, from whom would the member obtain the refund?
Anthem
Provider
Bank
Mike Brown had a service performed on March 3rd in Dr. O'Tool's office. Mike received a bill from the provider's office for $430. He is upset because his explanation of benefits states the claim processed out of network. What is the next action you should take regarding this claim for the member?
Check the provider status and verify if the claim is processed to the correct benefits
Call the provider to obtain a refund for the member
Send the claim for an adjustment since the member is not happy
What can you NOT use to search for a claim in Solution Central?
Action Code
Claim Number
Provider Name
Service Dates
Donald Williams is visiting a friend while traveling in Spain and breaks his leg. Donald has Global Core benefits on his policy and needs help.
What would you tell Donald?
Submit claims directly to BlueCard Services
You can only have services within the United States
You can only have services within your Home State
Email me the claim for processing and we will pay the provider
When speaking with a provider’s office and they tell you that there was a mistake on a claim that they submitted and requests verbally for you to make the adjustment, what would you do?
Make the change on the claim we have and send for adjustment
Instruct the provider to make the correction and resubmit the claim
Tell the provider that no corrections are allowed
When reviewing a claim with an action code of R00000, what is a common reason for that action code?
Benefit Maximum me for therapy
Claim applied to Deductible
The amount of the claim is reduced, then the balance of the bill is subject to the member's copay
When a member travels outside the United States and receives outpatient care, what would they owe?
They must pay the provider and submit a claim directly to BlueCard Global Core
Nothing. The provider will file the claim for them
Only what their benefits state - standard co-pay, coinsurance, deductible and non-covered charges
