Introduction to Claims
How can claims be submitted?
Via Paper or Electronically.
If a claim is not submitted within a 12 month timeframe what is the most likely outcome?
Charges can be denied.
The Timely Filing rule for Institutional, Hospital or Emergency Hospital Claims is based on?
The Discharge Date
What is a claim form?
Legal Documents used for recording all services/procedures rendered for patients.
How do you access claim details?
You can locate the claim on the Claim Summary Page and click the hyperlink or Type the claim number into the Claim/Pre-D field on the claim summary page and click Go.
What is a Claim?
Notification to an insurance company that payment of an amount is due under the terms of the policy plan.
The timeframe a provider or member has to submit a claim to health insurance carrier for reimbursement is called?
Timely Filling
What is the reason in which a timely filing can be extended?
Natural Disasters
The types of claim forms are:
1. CMS 1500
2. Electronic
3. SuperBill
4. UB-40
False, UB-40 is a musical group
Where do you access the Check Status Inquiry Tool in CRM Service?
On the Claim Detail Page in the CLAIM PAYMENT DETAILS Section.
The 2 systems used to process claims are CAM (Claims Administration Maintenance) and CRM (Customer Relationship Management). True or False?
False
Acceptable forms of proof for a claim appeal?
Electronic filing receipt
Certified mail receipt
A market Exception
Transmittal from the providing stating the date of submission
CMS requires members to be given _____ from the date of the prescription fill to submit their claim.
36 months or 3 years
What type of information does a claim form contain? Mention at least 4.
Dates of service, CPT Codes, service descriptions, charge amounts
Diagnosis and conditions to include ICD Codes
Insured name, address, phone number, and DOB
Provider Name, tax id number, addresses and phone number.
What is the purpose of Quick Links on the claim detail page?
Allow you to quickly access specific sections of the page to view/provide information.
What are the 2 Forms accepted for Claim submission?
CMS 1500 and UB 04
If a nonparticipating provider fails to submit the claim timely, what is the outcome?
The provider can and will charge the member for the service.
A corrected claim can be submitted when it is a true correction. True or False?
True
A CMS 1500 form can also be referred to as HICFA. True or False
True
Where can you locate the provider's CIS ID in CRM Service?
On the Claim Line Items section in the Provider Indicator-Show more link.
The 3 possible outcomes of a Claim.
1. Paid
2. Denied
3. Pended
Random Question from Trainer
Answer Variable
When does Timely Filing not apply?
When Humana is primary if a secondary carrier pays or denies as primary within the timely filing limit.
What are the 4 main sections claim forms are grouped in?
1. Diagnosis/Condition
2. Member
3. Provider
4. Service/Procedure
From the Claim Detail page, how can you determine if an Auth or Referral was required for the service(s) on the claim?
The Autho/Referral requirements Link Will Provide access to the CRM Service form. Using a series of questions, it helps determine if an authorization or referral was required for the service billed on the claim.