Claim Outcomes
What are the 4 outcomes that you can see on a claim?
Paid
Denied
Parcially Denied
Pended
What are the type of codes you can find on the claim?
CPT
HCPCS
REV
What is the Role of PAF?
Is a group of specialist who investigate claim inquiries using different systems to provide a final determination. Also help CCS with clarification on how to review a claim.
What are the CRM screens that you will use to retrieve claim information?
Claim Summary page
Claim Detail Page
What CAS stands for?
Claim Administration System
True or False! If a Claim is Paid an EOB is sent to the member.
True
Only if the member has a responsibility amount.
What is the Mentor doc to know the POT?
Place of Treatment Codes
What are the hours of operations and phone number of PAF?
Mon - Fri 8 AM to 5 AM EST
1-8777-669-2839
In which CRM screens can you use the logging feature?
Claim Summary page
Claim detail page
Provide the definition of CAS?
Mainframe system use to process claims, record and locate information related to members.
What is the time frame for a pended claim to be processed?
There is no time frame.
Pended claims are reviewed by a CRU specialist.
What are the characteristics for CPT, HCPCS and REV codes?
CPT - 5 numbers, use by physicians.
HCPCS - 5 Characters - one Alpha letter followed by 4 numbers
REV - 3 to 4 characters, use by hospitals and facilities
What is the Mentor doctument to know PAF information?
Claim Final Review and Routing to CRU Overview.
Phone a Friend to Research Claims.
Name what information can you find on the claim detail page.
Beging date of service, End date of service, Source, Claim type, Authorization number,platform, last processed date, etc.
What are the CAS clients we handle and the states?
CAS 56 - TX and AZ
CAS 57 - FL and GA
CAS 58 - All other ,markets
What are some reasons a claim can be denied?
No Authorization on file
Services are not covered
Incorrectly Submitted
Missing Information
What is the type of code for the following?
61500, 0343,A9500 and 86304
61500 - CPT code
0343 - REV
A9500 - HCPCS code
86304 - CPT code
Can you name some scenarios/claims where PAF cannot help with?
G&A
Home Health Claims
Skill Nursing
Name information that you can find when line item is expanded.
DX code, Units, NPI, TIN
REV code, Modifiers, Place of treatment, Cause code, etc.
What is the command line for the MHI screen?
MHI,SSN,Suffix,First inicial,RL,Claim number
Practice!! The trainer will give you an H number and you will have to explain the outcome to the class.
Practice!
Provide description for the following modifiers.
L, K, DXP, A
L - Mbr responsibility
K - Check status
DXP - Diagnosis codes
A - Adj
What is the Note template when transferring the case to PAF?
Claim number, Issue in detail, caller contact information,follow up if needed, #PAF,If PAF is not available.
What is the CAS Claim Prefill link for?
Access the Web system and opens the CAS screen (MHI) claim detail information.
What is the command line for the MDI screen?
MDI,Mbr id/SSN,Suffix,First inicial,RL code, MMYY