Specialty Care
A member is seeing a rheumatologist for newly diagnosed rheumatoid arthritis and asks if office visits are covered.
Specialist benefit section. Diagnosis, proposed treatment, and any specialty medications that may require authorization.
A member reports a claim denied as "non-covered service."
What resources should be reviewed first?
Claim details
Claim notes
Benefit brochure
EOB explanation code
A member has coverage under their spouse's plan and RCBP.
What is the first thing we should determine?
Which plan is primary.
A member calls about a denied claim.
Name the FIRST resource you review.
Claim details screen.
A specialist orders advanced imaging.
Before discussing claim outcomes, what should be researched?
Authorization requirements and status.
A member's neurologist ordered nerve conduction studies following complaints of numbness and tingling.
What additional information should be gathered before discussing coverage?
CPT Code
Diagnosis code
Participating provider status
Authorization requirements
A member says, "My doctor says they billed correctly."
Does that automatically mean the claim was processed incorrectly?
No.
Further investigation needed:
Coding
Authorization
Benefits
Eligibility
COB
A claim denies requesting information about other insurance.
What is the likely issue?
COB information is incomplete or outdated.
A member asks if surgery is covered.
What two codes should you request whenever possible?
CPT Code
Diagnosis Code
Authorization exists but the claim denied.
What should be investigated?
pected Answer:
Dates of service
Procedure code match
Claim notes
Authorization details
A member calls regarding treatment for obstructive sleep apnea and asks if their CPAP machine is covered.
What benefit category should be reveiwed?
Durable Medical Equipment (DME)
Discuss:
Medical necessity
Authorization requirements
Member cost share
A member's surgery processed at a much higher member responsibility than expected.
What are three possible causes?
Deductible
Coinsurance
Out-of-network provider
Benefit limitations
Incorrect authorization
COB issue
A dependent child is covered under both parents.
What common rule may determine primary coverage?
Birthday Rule.
What resource should be reviewed for authorization questions?
MedCompass
A member asks if authorization approval guarantees payment.
What is the CSR response?
No.
Authorization does not guarantee benefits, eligibility, or claim payment.
A member's oncologist recommends PET imaging as part of cancer treatment planning.
How much will the member be expected to pay out of pocket?
A claim is denied for medical necessity.
What type of action may be available to the member?
Appeal process
Additional documentation
Medical records review
A member recently enrolled in Medicare but is still actively employed.
What must the CSR determine before advising the member?
Coordination order between Medicare and active group coverage.
Name five resources you might review on a complex claim call.
Claim Details
Claim Notes
MedCompass
Eligibility
Brochure
COB Information
Adjustment History
Cost of Care Tool
The authorization was approved after the claim denied.
What next process should be considered?
Rework/reprocessing review.
Our member calls regarding infertility treatment and asks if IVF will be covered.
What are the key items a CSR should review before quoting any benefits
Specific infertility benefit language
Plan limitations
Authorization requirements
Provider requirements
Exclusions and cost share
A provider states a corrected claim was submitted but the original denial still appears.
What should be reviewed?
Claim history
Corrected claim receipt
Adjustment records
Reprocessing activity
A claim denied for COB has now received updated insurance information.
What question should be asked next?
Can the claim be reworked or reprocessed based on the newly received information?
DAILY DOUBLE!!!!!
A member calls stating:
"I received an MRI, later had surgery, recently added my spouse's insurance, and now my claim is denied because authorization and COB information are being mentioned. My provider says they billed correctly."
Walk us through your investigation.
Must mention:
✅ Eligibility review
✅ Claim status review
✅ Claim notes
✅ COB investigation
✅ Authorization review in MedCompass
✅ Benefit review
✅ Denial reason
✅ Next steps
✅ Appropriate member expectations
A member calls regarding a denied outpatient surgery claim. The claim shows a denial, there is another insurance policy on file, and the member wants to know exactly what they will owe once everything is fixed.
The CSR should:
Verify eligibility.
Review claim status and notes.
Investigate COB information.
Research authorization status.
Review applicable benefits.
Determine whether rework is appropriate.
Explain next steps.
Never guarantee claim payment or member responsibility.