Claims Basics
What is the first step in processing a claim?
Verify member eligibility
What does deductible mean?
The amount the member pays before insurance begins covering costs
What’s the first thing you should do when answering a call?
Greet and verify the caller
What law protects patient health information?
HIPAA
What does TPA stand for?
Third Party Administrator
What does EOB stand for?
Explanation of Benefits
What’s the difference between copay and coinsurance?
Copay = fixed amount, Coinsurance = percentage of cost
What’s a good empathy phrase you could use with a frustrated caller?
"I understand how frustrating this must be for you”
What must you never disclose without proper authorization?
Protected Health Information / PHI
How many customer care reps are on our team?
6
True or False: A denied claim can never be appealed
False
Define “out-of-pocket maximum.”
The most a member will pay in a year for covered services
What’s active listening?
Fully focusing, repeating back, clarifying
What’s the purpose of prior authorization?
To confirm medical necessity before a service is covered
What snack is most popular in the breakroom?
Coffee
Who is financially responsible in a self-funded plan?
The Employer
What’s the term for services not covered by a plan?
Exclusions
When escalating a call, what key information should you provide?
Caller’s issue, steps already taken, urgency
What’s a TPA (Third Party Administrator)
An organization that manages employer-sponsored health plans, claims, etc.
What year was our company founded?
1973
What’s the standard turnaround time for claim processing under most contracts?
Typically, 30 days
What’s the difference between in-network and out-of-network coverage?
In-network = contracted rates, lower cost; Out-of-network = higher cost, no contract
What’s the “golden rule” of customer service?
Treat callers how you’d want to be treated
In appeals, what’s the difference between an urgent and standard appeal?
Urgent = time-sensitive for health/safety; Standard = typical review period
What’s one-word clients most often use to describe our service?
Reliable