Claim Essentials and Inquiries
Members with what type of MyHumana account can view their medical claims online at MyHumana.com. Claims are also found on Humana's mobile app under the Coverage icon.
Activated MyHumana account
What is a Preauthorization?
Preauthorization is a policy provision requiring a member's doctor to obtain approval ahead of time before Humana will cover the costs of a procedure, test, treatment, or medical device.
When reviewing CAS, what screen displays a list of claims on file by claim number and provider name?
Multiple Claim Summary Inquiry (MDI) screen
The Multiple Claim Summary Inquiry (MDI) screen in CAS displays a list of claims on file by claim number and provider name. The MDI screen also allows you to search for claims not found in CRM by a specified date range.
What is Subrogration?
Subrogation investigates claims paid by Humana that are identified as accident and injury related.
What is the Claims Research Unit (CRU) team?
CRU is a specialized team of Humana analysts who investigate CAS claim inquiries using various methods and systems to make a final determination.
The CRU team examines the claim to determine if the original outcome should remain unchanged or overturned.
Cause Code.
What would you see listed as the category for Accident?
ACC: Accident
ILL: Illness
RC: Routine/preventive care
When would an authorization or referral NOT be needed
1. Any emergency ambulance transportation to ER.
2. Any ambulance services dispatches via 911.
3. Ambulance services when there is a paid ER Facility claim for the same date of service.
When speaking with a member about Coordination of Benefits, what Classification would you use?
Classification: COB
What type of care is designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than a cure.
Hospice care
True or False:
Members have the right to file an appeal request online or in writing?
Members have the right to file an appeal request online or in writing. Advise members of their appeal rights including filing requirements, deadlines, and notifications as indicated in Mentor.
True of False.
Timely filing is the timeframe a provider or member has to submit a claim to Humana for reimbursement. Timely filing is also referred to as proof of hardship.
Timely filing is the timeframe a provider or member has to submit a claim to Humana for reimbursement. Timely filing is also referred to as proof of loss. If a claim is not submitted within that timeframe, charges can be denied.
What is PARE?
Pathologist, Anesthesiologist, Radiologist, Emergency Physician (PARE).
Many of our dual eligible members have an additional benefit with $0 cost called what?
Cost Share Protection (CSP).
This means the member has $0 cost for expenses such as premiums, deductibles, coinsurance and copayments. This also means they cannot be balanced bill, regardless of the provider's network status or whether they accept Medicare assignment.
True of False.
Durable Medical Equipment (DME) is disposable or available to use only one time?
False.
DME is NOT:
Disposable or for one-time use.
Available over-the-counter at a retail pharmacy.
A convenience item or hygienic equipmen
True or False:
Pended Codes:
01H, 0SX, 08/, 0F\, 0H), 01!!
False.
Pended claims will have the following pend codes:
01J, 0YX, 08\, 0J\, 0H(, 01!
The Quick Start Plus (QS+) application is a documentation tool used while working in CRM. Where is it accessed?
The Quick Start Plus (QS+) application is a documentation tool used while working in CRM. It is accessed from the QuickStart+ tab in the static footer
Detailed formation is found in the Claims Administration System (CAS) on the Referral Summary Inquiry (RSI), Referral File Inquiry (RFI) and Preadmission Inquiry (PRI) screens.
Please describe CAS, RSI and RFI.
RSI: The RSI screen provides the same general information found in CRM.
RFI: The RFI screen provides additional information such as the referring and treating providers participation status.
PRI: The PRI screen is where additional referral details are stored such as diagnosis, procedure codes, and number of days authorized and used.
What mentor would you access as the starting point for all claim calls?
Claims Determination Overview
Name 1 of the 4 common reasons for Claim Adjustments
1. A claim is denied and later allowed based on additional information.
2. The wrong provider was paid.
3. A duplicate claim was denied.
4. A claim was paid out of network and should be paid in network.
If a claim has been processed AND the caller is dissatisfied with the claim processing, what step would you take next?
If a claim has been processed AND the caller is dissatisfied with the claim processing: Go to Medical Claims Determination (Mentor)
Medicare members that are dual eligible could qualify for Cost Share Protection (CSP). What is CSP?
CSP is a Medicaid program that covers the cost sharing for services provided by Medicare plans. When a member is cost share protected, they are not responsible for paying their out-of-pocket share (such as, copayment, coinsurance, deductible). Providers must bill the state Medicaid for the members cost share.
Where is the provider speciality information located in CRM?
Provider specialty information is found under the Provider Detail section of the Claim Details page.
Logging into CAS through the DIG toolbar ensures the correct client sessions open for you. What option do you select in the DIG login menu?
HODMOD4.
Logging into CAS through the DIG toolbar ensures the correct client sessions open for you. This is done by selecting the HODMOD4 option on the DIG login in menu.
Note: Logging into your systems through DIG at the start of each day will prevent you from experiencing any CAS access issues.
Home Healthcare (HHC) does not allow patients to receive treatment within their own home and they will need to be admitted to a hospital or nursing facility.
False.
HHC allows patients to receive treatment within their own home instead of being admitted to a hospital or nursing facility.
What screen are CAS claim details located?
CAS claim details are found on the Medical History Inquiry (MHI) screen.
This screen is accessed by clicking the CAS Claim Prefill shortcut link on the CRM Claim Details page. Unless multiple Humana policies exist, claim details automatically open in a new window.