TERMS
This term is used for members who are covered by more than one insurance.
What is COB ?
Member is scheduled for a visit to his allergist, he goes to the doctors office. What POS will the provider bill on the claim?
11
This code consists of three digits, is located in the upper right hand corner of the UB04
Type of Bill
Claim # 17072H976700 What type of claim denials are these.
Claims Xten
Provider calls in to see when member id # 71260836 was last active, what do you tell them ?
Coding Systems
Place of service code for Ambulatory Surgery Center
24
A provider has called in regarding a claim that was denied for no authorization. Through your research you locate the authorization in Prospective UM, AND determine that the claim should be adjusted. What queue would you route your ticket to ( its a four digit number)
1001
Claim # 17285H683400 is there an EOB, Was the claim processed correctly? What would you tell the provdier?
Yes the claim processed and paid correctly, There is no EOB attached because an EOB was not required.
Is member id # 35236809 covered for office services for dos 2-1-2010
If medicaid allowed amount is Less than the primary c carrier's paid, Medicaid Pays Zero. If medicaid's allowed is MORE THAN the primary carrier's paid, Medicaid will pay the lesser of the total member liability or the difference between the medicare paid and medicaid allowed amounts
LESSER OF LOGIC
Place of service code for ER
23
You received a call from a provider who is new to Horizon NJ Health, they have a member that was referred to them by their PCP and they needed to know if Mental Health Benefits are covered under their plan. What do we tell the provider
Yes it is covered by submitting the claim directly to the state medicaid address ( Fee for Service)
Claim # 17111141920 in facets this is a cob claim with medicare as primary, did this claim pay correctly according to LOL?
Yes claim paid correctly.
Under authorization number # H24580120 What is the primary diagnosis and description?
7991 - Respiratory Arrest
These codes consist of two digits and are placed on professional health care claims.
Allows for efficient transfer of huge amounts of information from medical providers to health insurance carriers and also allows for uniform documentation between medical facilities
Medical Coding
These providers will bill on a HCFA 1500 form Select all that apply :
Internal Medicine
Pediatrician
DME Provider
Hospitals
Internal Medicine
Pediatrician
DME Provider
Claim # 16134G547200 the provider wants to know why the last two lines of the claim were denied. What would you advised the provider?
86901 was denied denied correctly for no authorization, and 86850 denied correctly for services being capitated to another provider
Under Auth number H30851510 How many units were requested? And how many units are remaining?
30 Requested , Remaining 13
What do we call healthcare providers that contract with Horizon NJ Health, who agree to treat our members and accept our payment in full
In- Network
Facets claims will reflect different claim statuses, depending on where they are in processing phase. Which claim statuses allow us to provider payment and denial reasons to the provider?
Status code 01, status code 02
Mltss covers non traditional services which of these are an example of that: Vehicle or Home Modifications, Chore Services, Chiropractic Services, Laboratory Services.
Vehicle or Home Modification and Chore Services.
A provider calls to ask if cpt code 78815 is covered and does it require an auth, what would you tell them ?
Yes it is covered and requires an authorization from NIA(EVICORE)
Under auth number H38917380 what is the name of the servicing provider/ facilty ?
Capital Health Regional Medical Center