Claims
Which intent do we use to see claims?
Review Claims History
the method of integrating benefits which are payable under more than one health insurance plan, so that the insured person's benefits from all sources do not exceed 100% of the allowable medical expenses.
Coordination of Benefits
Common Procedural Terminology
What is CPT
The more of this there is, the less you see. What is it?
Darkness
When a member is being charged over their responsibility on a claim(s).
What is Balance Billing
The claim is not yet payable because it is being reviewed to resolve some discrepancy.
What is pending
What I do when I can't find a medical claim
Contact RSS for assistance
System(s) used to search codes?
Knowledge Library
KC - Claims codes and ice Index
You have me today,
Tomorrow you'll have more;
As your time passes,
I'm not easy to store;
I don't take up space,
But I'm only in one place;
I am what you saw,
But not what you see.
What am I?
Memories
Payment on a claim was not made for various reasons
What is Denied
Will assist with determining liability and next steps for NICE and COSMOS claims with denial or adjustment codes.
What is Claim Decoder Macro
How do you tell the difference between a NICE Claim and a COSMOS claim?
COSMOS - "A" at the end of claim number
NICE - Reopened
POS 02 - what am I
Telehealth
If two snakes marry, what will their towels say?
Hiss and hers
System that has member information, plan and benefits, recent interactions, and claims and billing information
What is Maestro
A member calls wanting to know how long it will take for a claim to be initially processed from a Par Provider?
30-60 calendar days
Means paying an agreed upon dollar amount per month for each member assigned to a provider
What is Capitation
Code 95120
Allergy & Clinical Immunology
I am a box that holds keys without locks, yet they can unlock your soul. What am I?
A piano
When a member has made a threat to harm themselves or someone else
What is One Breath
This section contains information about Total Charges, Total Member Responsibility, Provider Liability Denial as well as, Payment Detail?
What is Financial Detail under Claim
Most insurance companies including UHC use the rules established by what organization that are applied in a specific order until it can be determined that one plan pays first, secondary or tertiary?
NAIC - National Association of Insurance Commissioners
Proceudre 50.5
Liver Transplant
Three playing cards in a row. Can you name them with these clues? There is a two to the right of a king. A diamond will be found to the left of a spade. An ace is to the left of a heart. A heart is to the left of a spade. Now, identify all three cards.
Ace of Diamonds, King of Hearts, Two of Spades.
Parts A, B, and C
What is Medicare Advantage