Claim Essentials
What information is needed to file a claim
What is Type of Bill
Type of bill (TOB) codes are 3-digit alpha-numeric codes which indicate the type of bill for the primary payer.
What screen is your starting point in CAS
MHI screen - Displays the history of all claims on an individual member, or specific claim information when the claim ID is typed.
In order to have a CSNP plan what form must be completed and sent in
Verification of Chronic Condition Form
What is Fide/Hide
Fully and Highly Integrated Dual Eligible (FIDE and HIDE) Special Needs Plans (SNP) are dual eligible special needs plans providing a combination of:
What is the timely filing for Out-of-Network Providers
Out-of-Network Providers: 12 months
What is a Cause Code
Cause codes are Humana-specific terms that categorize services rendered. They interface with the plan loading system to generate group-specific benefits based on service and diagnosis on the Claims Administration System (CAS) claim. All diagnosis codes have cause codes.
What is the CRI screen for
Displays the coordination of benefits (COB) information for a family or individual.
What screen can you locate information about the VCC form
CSNP screen in CI
What could be a difference between a Hide vs Fide plan
All FIDE members have LTC, but HIDE members may or may not have LTC
What is the timely filing for In-Network Providers
In-Network Providers: Follow Original Medicare timely filing time frame, which is 12 months. Unless otherwise specified within the provider’s contractual agreement with Humana Medicare Advantage
What is Procedure code modifiers
Procedure code modifiers are two-digit codes attached to current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) codes. Modifiers are alphabetic, numeric, or alphanumeric. Examples of modifiers are RT, LT, 25, and F1.
Which screen displays claims in a requested month and year for member
MDI screen
The standard Humana deeming (grace) period for DSNP plans is 6 months except for which state and how many months does that state get in the grace period
Tennessee DSNP which is 3 months
What happens if a member has a loss of LTC or Medicaid Eligibility
What is an Explanation of Benefits
A traditional Explanation of Benefits is a letter to the member that has the details of a single claim.
What is ex code 0<D
A coding error was detected. The diagnosis code submitted is not valid when billed as a primary diagnosis.
What screen Displays information about a provider’s contractual agreement specific to the line of business (LOB).
CFI screen:
What is the MEVH screen in CI
The MEVH screen in the CI system houses Medicaid information directly related to the member's enrollment.
What portion does Humana pay on a Hide/Fide Claim
Humana pays the Medicaid cost share at the same time as the Humana Medicare payment
What is a Smart Summary
A monthly, personal health finance and benefits statement that includes a member's claim information
What is CPT code 99213
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
What is the DMI Screen
Displays the healthcare common procedure coding system (HCPCS) associated with the durable medical equipment (DME) item per member per claim.
and/or
Displays the HCPCS associated with the DME item per member.
What is the ISNP
Institutionalized Special Needs Plans (I-SNP) are for members who have been in an institutional facility for 90 days or more.
If the member wants to travel somewhere other than a medical appointment or LTC program service what can they use
They can use their LTC expanded transportation benefit