Claim Basic
Pharmacy / SNF/ Hospice / Hospital
What are facility services?
This is how to identify a reversal in CRM/Qnxt.
What are looking for the parenthesis or a minus sign?
The claim was received on this day.
What is the Clean date?
These medical services are not considered a necessity.
What is a Prior authorization?
We use this system to review the actual claim submitted.
What is the claim viewer?
The form for PCP/Specialist visits.
What is a CMS 1500 / HCFA 1500 form?
This is how Molina will cover an underpayment.
What is paying the difference only?
This is used to verify a service is covered for Marketplace.
What is the CMS fee schedule?
Claims will deny unless the following are in place, an authorization, single case or continuity of care agreement.
What is an Out of network providers?
This system is used to verify where and when the funds were deposited.
What is US Bank?
This code is found on the UB04 claim form in box 42.
What are Revenue codes?
The department who handles any recoupments .
What is Cost recovery?
This code is used to search the fee schedule.
What is the Current Procedural Terminology Code?
This is when a provider give you other coverage information for a patient.
What is a COB discrepancy?
This system is to review the correct medication coding was used.
What is RedBook/ NDC coding?
These codes are 3 to 7 digits long.
What are ICD 10 (Diagnosis) codes ?
This number is assigned to the member by the provider.
What is the Patient Account number?
This percentage amount could change the next time the contract is renewed with the provider.
What is the Contractual allowance amount?
This is when the patient would need to contact the state for updates.
What is an eligibility denial?
This system is used to verify CES, Optum and CCI denials.
What is Cotiviti (IHT tool)?
This range of codes are for Labs and Pathology.
what are the 80000 - 89999 codes?
This is Also known as an Remittance Advice.
What is an Explanation of Payment?
This is abbreviated as the DRG.
What is Diagnosis Related Grouping?
This provider has been paid the maximum amount for this type of service.
What is a benefit limitation?
All medical coding can be verified with this system.
What is EncoderPro?