General
A provider bills a member for more than their claim responsibility. What issue should be investigated?
Balance Billing
John calls and requests that a copy of his Explanation of Benefits (EOB) be reprinted and mailed to his home address. What action should the advocate take?
Complete the EOB reprint request using Doc360 or the Member Materials - EOB Requests process if Doc360 is not available.
How many days is the standard claims processing turnaround time?
30 Business days
A member calls with a question about a Behavioral Health (OBH) claim. Which job aid should you use to understand how to route the claim for reprocessing?
OBH Claims Routing
If a claim is not found in Claims Search or PCD and it has been less than 30 days since submission, what should you advise?
Advise the member that claims can take up to 30 days to process and allow more time
Mr. Miller calls to understand why he was billed for a medical claim and wants an explanation of the amount he is responsible for paying. In Maestro, where should the advocate review this information?
Financial Detail
A member calls about a denied claim. Which tool can help determine liability and next steps after reviewing the claim in Claims Search and PCD?
Claim Decoder Macro
A member calls about a medical claim that was denied due to a Coordination of Benefits (COB) issue. What should the advocate do first?
Refer to the Medical Coordination of Benefits - Index to update the COB information on the member's account.
A member calls requesting reimbursement for a covered medical service they paid out of pocket. Which job aid should the advocate use?
Direct Member Reimbursement (DMR) - Index
A member calls about a denied claim and the denial code indicates the provider is not approved to receive payment from the Medicare program. What should the advocate tell the member?
The member is always responsible for paying the denied claim.