Claims Day 23 Practice

I love Claims

100

If a claim is coded as Diagnostic but the member states it should be Preventative, what should we do

Reach out to the Provider and them Resubmit the Claim

200

This is also known as a diagnosis code

ICD-10

300

After an appeal is filed, how will the member/provider be notified

By Letter 5-7 Bus days after the determination is made

400

What task in solution central lets us look at claims

Manage Claims

500

Before we process a claim it is sent to a _____ to ensure there are no errors

Clearing House

This seems Easy

100

This type of code provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code

Modifier Code

200

This Type of Code is used to document procedures performed in a doctors office

Procedure Code

300

What are the 5 Claim Statuses 

Open

Denied

Rejected

Paid

Deductible

400

This is the name of the system we use to Check the status of a Grievance/Appeal

Nextgen

500

These Codes are descriptions and dollar amounts charged for hospital services provided to a patient

Revenue Codes

I know this Claim

100

We process claims automatically by a processes called?

Adjudication

200

This type of Claim form is used when Professional providers want to submit claims for their services

CMS-1500

300

This is the system we use to view Pre authorizations

Member360

400

When an OON Provider charges more than our allowed amount this happens

Balance billing

500

If a Member disagrees with how we processed a claim, they have a right to file what

Appeal/Grievance 

Iv Seen this B4

100

This is the type of Claim form a Facility will use when

UB-04

200

True or False an In Network Provider can charge a member more than what the EOB states

False

300

These Types of Claims will never count towards a members deductible

Preventative

400

If we needed to check a members service limits where in SC can we go

Accumulators  

500

This is the term used when a member has more than one Insurance Provider

Coordination of Benefits (COB)

This Claim Got Me

100

What are the first 7 Letters of an Appeal Confirmation Number

APP-COMM

200

Where can we find an EOB for a claim in Solution Central once we have located the claim

Under the Perform Next Action Dropdown

300

This is the term used to describe the specific dollar amount that we have negotiated with a provider

Allowed Amount

400

What is the Service Location Phone Number for this Member ID 182M56033

844-390-4133

500

True or False we can only Adjust a claim when we made an issue processing it

True