Mentor
What Mentor do you use for your step by step call flow?
Incoming Calls CCC Provider
What is the department that handles Overpayments/ Deduct?
Provider Payment Integrity (PPI)
What is the Next steps for the following EX Code?
1IL
Advise the caller that a corrected claim is needed. DO NOT send to CRU as CRU cannot adjust the claim.
If the caller is unsure or questions what needs to be corrected, advise that we cannot tell them how to bill and refer them to Provider.Humana.com and claim payment policies for Humana policies and advise if there isn't a Humana policy that we follow CMS and they can search CMS.gov. If needed, refer them to their training department, billing department or clearing house.
What is the CAS screen that displays hospital or facility demographics, address, and phone number
PDI Screen (H)
What is ARI used for?
Locating Remittance and payments for providers when you cannot locate specific information in CRM.
What is the mentor that goes over the PHI information needed to be obtain before you can assist the caller?
HIPAA Overview CCC Provider
What department handles claims reprocessing?
Claims Rework Unit (CRU) Routing
What are the three main status's of a claim?
What is the modifier SB used for on the MHI line?
To see the Split Bill indicator codes
When do we use EMME?
To locate letters/ correspondences that were sent to providers.
What Mentor document do you use for Integrated Benefits?
VA H2875-001-000 Integrated Benefit Grid 2026
VA H2875-003-000 Integrated Benefit Grid 2026
What is the Timely Filing for VA Medicaid Claims?
Clean Claims
For first-time physician claims, the claim must be received within 365 days of the first date of service (DOS) to be considered timely. For first-time facility claims, the claim must be received within 365 days from the through date to be considered timely.
What is three specific details you can see when you expand the Line items in the claims details page?
Modifier, Place of treatment Code (POT/POS), Units
Double Points!!
What is the CAS Screen that you use for finding a member's Other Insurance (OI) information?
CRI
What is E-Hub used for?
To locate electronic claims that were submitted through Clearing House/Availity.
What Mentor Document do you use for when a provider is asking for their Appeal rights?
Double Points!!
Provider Complaints Virginia Medicaid CCC Provider
What is the following Acronym mean?
P.A.R.E
Pathologist, Anesthesiologist, Radiologist and Emergency Room Physician
How can I tell if it is a provider billing a claim or a hospital?
Look for Bill Type for Hospital
Look for Frequency for Physicians claim
What selection code can you use to go from the ISI screen to the CSI screen?
Selection: P
What is Humana Image View Station used for?
To locate paper claims and OI EOB's
What Mentor would you use if a provider ask for a Supervisor?
Escalation Procedure CCC Provider
What is your scripting for when you start a call?
"Thank you for calling Humana. My name is ___________. How can I help you?"
What is the Quick Link in CRM that can take you to CAS from te Claims Detail page?
CAS Claim Prefill
What happens when the Quicklink in CRM does not work or says it's not available?
You would need to check if you're signed into CAS and not timed out.
What system do we use to locate processing details of a claim when it comes to how it was priced?
CIS PRO