Claim Essentials
Are some dental treatments covered under Humana medical plans?
Yes
What are some Medical Resources Available to use?
Debut, Coverage Issues, Mentor Benefit Grid
Which CAS Screen Contains Member Benefit Accumulation Information?
MAI
Which systems or resources can be used to determine if a claim is corrected?
CRM, the claim image, or CAS.
Claims can be denied if __________ isn't received when required.
authorization
What is the maximum timeframe for submitting a claim to Humana?
12 months (1 year) from the date of service.
What are the two common payment methods mentioned in provider contracts?
Fee-for-service and capitation payment.
Which CAS screen contains claim details?
The MHI screen.
What codes do hospitals and skilled nursing facilities typically use to describe services rendered?
REV (Revenue) codes.
Who typically receives the referral once it is generated?
Humana and the specialist or other physician, if required.
What are the Claims Form Used?
CMS-1500, UB-04, Superbill
What is the purpose of Cause codes in claim processing?
They categorize the reason the healthcare services were rendered.
What can be added in the MHI screen to locate additional claim information?
Modifiers.
What priority should a CRM case be set to if there are access-to-care impacts?
Critical.
Who is responsible for paying covered services after a member elects hospice coverage?
Original Medicare.
What can you use as Procedure Code?
HCPCS Code, REV Code, CPT Code
What Claim Information can you not disclose to Member:
Diagnosis, Procedure Code, Diagnosis Code
What is eHUB used for?
It is used to view electronic claim submissions for charges not found in CRM.
What does HIVS stand for?
Humana Image View Station.
An SNF benefit period is limited to _____ days, and a new benefit period begins after a break in care of _____ days.
100 days; 60 days.
What are some possible outcomes for Claim Processing:
Paid, Partially Denied, Denied
Who is responsible for paying the member's cost share when a member qualifies for Cost Share Protection?
The provider must bill the state Medicaid program for the outstanding amount.
Which resource should agents reference for claim-related call handling guidelines?
The Claims Determination Overview Mentor document.
If Humana sends the reimbursement check directly to the member, who is responsible for paying the provider?
The member.
Under which two Medicare benefit categories might a drug be covered?
Part B (medical plan) or Part D (prescription drug plan).