Font size
WorksheetsCS Member Intensive Claims Assessment
Total questions: 20
Worksheet time: 11mins
Claims can be rejected because the provider incorrectly submitted the claim. A provider may have billed with inaccurate medical coding, or the claim was not completed.
TRUE
FALSE
If a claim shows a Denied status, the charges were denied. It may contain incomplete or inaccurate information. Some claims can be denied if the plan deems the claim medically unnecessary or it's not a covered benefit. In addition, providers may need to resubmit the claim for reconsideration.
TRUE
FALSE
Why is it important to keep up-to-date Coordination of Benefits (COB) information on file?
To ensure accurate records for claim processing
To reduce grievances and other escalations
To provide a positive experience for our members and providers
To maintain quality assurance and corporate compliance
All of the above
Which term is NOT a valid claim status?
Pending
Withdrawn
Approved
Rejected
Denied
A member has questions about a claim for outpatient hospital services. Select the claim form that should be used for these charges.
Institutional (UB 04 / CMS 1450)
Professional (HCFA 1500 / CMS 1500)
What are TWO reasons a provider might bill a member?
They’re competing in a bidding war with another insurance company
They were unaware the member had insurance coverage
Their claim was denied or rejected
They raised their fees
Which THREE of the following are NOT considered balance billing issues?
Copays
Provider did not submit a claim
Deductibles
Coinsurance
A member has questions about the status of a claim. The claim is currently pending and was received 10 days ago. What is the appropriate response to this member?
Do not send the claim for review. Explain the 30-day processing time, and advise the claim can be sent for review if it is still pending after 30 days.
Send the claim for review by selecting Disagree/Dispute and capturing the necessary information.
Do not send the claim for review. Inform the member their claim is on its way to being approved and they should not worry.
Do not send the claim for review. Direct the member to call Provider Services to learn more about a pending claim.
Balance billing occurs when a member is billed by a provider for more than their cost sharing amount.
TRUE
FALSE
Which is NOT an example of balance billing?
Provider did not submit a claim to the Plan; Member is being billed
Provider submitted a claim for the member’s coinsurance amount; Member is being billed
Provider submitted a claim but it was denied or rejected; Member is being billed
Provider submitted a claim but was paid less than the amount billed; Member is being billed
A member calls in with questions about a dental claim. What type of call is this?
A Claim Inquiry call
An Explanation of Benefits (EOB) call
A Coordination of Benefits (COB) call
An Ancillary Claim call
These FOUR categories of additional health coverage may impact how claims are processed.
Spousal Insurance
Other Insurance
Accident Related Coverage
Reinsurance
Worker's Compensation
What are the THREE main reasons Members call us about their claims?
To ask why they received a bill/EOB
To request a paper copy of an explanation of benefits or claim history inquiry
To make a payment toward their bill
To verify if the provider was paid
Which of the following best describes a balance billing call?
The member is being billed by their provider for the difference between the provider's billed amount and the insurance allowed amount
The member needs to relay information regarding additional medical coverage that may affect the claim payment
The member needs help understanding the claim history outlined in their report.
The member has questions about adding supplementary services like dental and vision coverage.
Claims with Approved status indicate that the Plan has reviewed the claim, found it accurate and complete, and will pay out to the provider.
TRUE
FALSE
When Members say they are being billed for a claim that was denied, what Task or Call Driver is used?
Billing & Payment Task OR Balance Billing Call Driver
Log View Status Task OR LEP Call Driver
Claims Inquiry Task OR Claims Inquiries/Status Call Driver
Material Request Task OR Material Request Call Driver
If a member has another insurance provider, our Plan will always pay primary.
TRUE
FALSE
Which of the following is NOT one of the three (3) most common claim denial reasons?
Member not eligible on date of service
No authorization obtained
Coordination of Benefits
Taxonomy code missing or invalid
These TWO terms refer to the main types of provider payment methods.
Capitation
Contract
Fee for Service (FFS)
ATM
A claim is a form submitted to the health plan by the provider to receive payment for services rendered to the member.
TRUE
FALSE
