Pot Luck
TRUE or FALSE. The RAPS/HAIRPENS policy applies to the services performed by nonparticipating providers when they occur in a participating facility (outpatient, inpatient or surgical); the “N” in HAIRPENS stands for Neurologists?
False (e.policies- neotatologists)
In MEA, what Verb would the processor use to access the Coordination of Benefits information for a member/dependent
7ICB
To find a diagnosis in EWM, which INQ screen would you navigate to
TRUE or FALSE. Once a processor accesses an electronic claim and alters any of the data, there is a way to restore the claim to its original state without voiding and sending the claim back to the queue. Simply “clear” the screen using the proper keyboard command, and the claim will be refreshed (For Rumba Version 5.1, the standard command is CTRL + SHIFT + R).
False
We allow ___ Modalities/therapeutic procedures per date of service.
4
What place of service code should be used for Urgent Care claims?
20
Using MEA & the CUMB ID#: W215870776:
What is the member's date of birth, What type of medical plan does the member have with Aetna and What is the Plan Summary Code of the member's plan?
06/11/1952, Open Access Elect Choice, AA
Using EWM and Claim ID: ENY1DDGYD00;
What is the Date of Service (mm/dd/yy) for claim, What is the billing provider’s name, and What is the CPT Code billed on Line #3?
07/18/2019, Chi Sum, 92587
What is another name for the COB Order of Benefits Determination Rule for “Dependent Child/Parents Not Separated or Divorced Rule”?
Birthday Rule
What is the appropriate denial action code to apply on charges for modalities that exceed the number of modalities allowed per date of service for a Participating Provider.
w55
If the claim includes a charge for the CRNA and the supervising physician, we should allow ____ % of the allowable for the CRNA service?
50%
Using MEA & the CUMB ID#: W143141503;
Which dependent on the plan's coverage has terminated, What is the name of Rory's Primary Medical Carrier and Which dependent on the plan has Special Handling set in MEA?
Sinead, Magnacare, Patrick
When a claim line needs to be deleted, it is not possible to just erase the line. The ________ override must be used to remove the line from the claim but retain the data for tracking and reporting purposes.
DL
Where would the processor find the COB method that a plan sponsor has elected to use when coordinating benefits with another health plan for their employees?
COB Provision
What CXT Rule applies concurrency percentages for Multiple Surgery claims?
C060
Viant uses error codes to identify the reason they were unable to reprice claims. If Viant returns the claim with EOP Code 602, what Claim Level Override would be used to unlink from the NAP network if the system does not automatically select the non par PIN suffix
NP UPER
In EPDB - using PIN: 4265979;
What is the Individual Provider's Name, What is the Network ID for the provider's W. Pennsylvania Managed Choice Plan, and What is the provider's primary specialty?
Albert Abram, 02152, Rheumatology
When specific lines on a claim need to be segmented, the ________ override must be used on each line. By using this override the system will automatically carry over each line with the corresponding line item control numbers and UCK
SL
Individuals are entitled to Part A coverage on the first day of the month in which they turn 65?
True
Non-Physician Assistants are reported using modifier _____.
AS
The Center of Excellence (COE) is responsible for processing initial claims from nonparticipating providers who bill _______ or more.
$1000
In EPDB - using TIN: 860996161;
What is the name of the Provider Group that owns the TIN, What is Dr. Ann Marie Padilla's PIN, and For doctor Jay M Raymock, what type of Network was 09831 - Banner Health HMO LG C?
Desert View Family Medicine, 4627840, passive
Soft edits are used to drop a claim from auto-adjudication, alert a processor that additional investigation or action might be required, or advise that a claim meets certain criteria
True
When the ACAS Edit “PATIENT NOTES OF TYPE “ ” EXIST” appears in the Mid-Screen Display on the CP screen the processor can use the MMNT macro, but if the macro isn’t working, what should the processor key into the WINDOW field to access the Patient Notes for our member?
NTIPA
ClaimsXten (CXT) automates percentage payments for assistant surgical procedures. What percentage of the base fee (negotiated or R&C) for the surgical CPT code is paid for an assistant surgeon billing with modifier 81?
12%