Basics
Under which popup do we get NPI AND NDC details
DS
provider information and under claim header
Provider is asking further details on claim denial . claim is denied for benefits . what should we do ?
Raise a gi 152 asking clarification on denial
claim is denied for duplicate . when reviewed we find changes in diagnosis code . what is the workflow ?
raise 105 gi for multiple exams
claim is denied for medical records . we have medical records and in b2 we have closed mrr. what next ?
verify the records and attach the records in infor msg 178 ,since mrr is closed
navigation to check standalone pricing
shift f3--f9--f4--enter --enter
Under which tab do we get standalone pricing ?
search --> pricing --> get pricing
Claim is denied for authorisation . Provider submitted auth# and is asking to reprocess the claim . what should be done ?
raise a gi 152 from manual asking confirmation on denial
need from manual ..
when we find changes in physician name , what is the workflow ?
multiple physicians GI 152
when corrected claim is submitted what are the mandatory field to be checked ?
patient , subscriber name , member id and prefix , dos , pos , proc diag codes, mod , billed amt , units , billing npi and billing number
which popup is used to update manual pricing
MP
Under which tab do we get clinical editing in CIW ?
EDITING TAB
claim is denied with close out code 1079 . what is the GI reason code and comment ?
DFMC 1079 - Please confirm denial. If correct, please provide information on where this claim should be sent for processing. Include any phone numbers or addresses. --- GI 111
Claim is denied for 1296 dfmc . what is the workflow?
raise gi 100 crossover GI , comments from b2 dropdown
raise a gi 325 for determination
Fields to check for a duplicate case ?
patient name , provider details ( npi and number ) ,proc code , diag code , modifiers , pos , dos
Under which tab do we get stop data details ?
under claim data-- details
Claim is in open status 51 . what is our next step ?
check the b2 for sf df records is open or not .
claim is denied for 0706. what next should be reviewed ?
check for history claims after dos if paid for the same patient . If yes raise as per , is not found ask for confirmation on denial gi 105
how do we verify timely filing ?
in ciw , click on the ? under provider infor tab -- check the state -- see if the claim rcv date is within the start and end date ,if yes - we will consider the limit beside , if not , go with default limits
how do we validate NDC code ?
CIW -- click on NDC code -- code sets
wgs -- copy paste the NDC code in master drug data field and enter
Under which tab do we get history claims in CW ?
Search -- claims
what the basic claim review steps ?
claim type , bill type , tx comments, host or home denials , network , pricing ,
Claim is denied for cob updates 0085 ? provider states cob has been updated ? what next ?
we should raise gi 100 asking if the member has updated cob and when was the last update ?
need from manual ...
b2 has 172 sccf , what next ? we do have med recs. . also what if the 172 sccf is already paid ?
open the 172 sccf to see if we have open mrr . If yes , we will attach the records in the 17 sccf .
if 172 sccf is paid , we shud raise 175 gi in our sccf stating reference sccf is already paid .