Claims General
Who processes claims manually?
Claims Specialist - Internal
How long is a claim number
It is a unique 15-digit number
What is claim adjudication?
The process where a claim is either automatically or manually processed (depending on the information provided
What code is 5 digit number commonly used for procedures
CPT code
How many CAS clients are there
3 clients
Name 2 types of care
Preventative
Diagnostic Testing
Hospital and Facilities
what it the allowed number of months for timely filing?
12 months
How long is a common POT code
3 digit alphanumerical code
What is modifier A used for?
To check if provider accepted medicare assignment at time of claim
What is a claim (Summary)
The claim is a bill that is sent to Humana by the provider for services rendered.
Who uses claim form CMS-1500
Providers and professionals
What is medicare Assignment?
Medicare assignment describes the fee structure that providers agreed to be paid by Medicare for their services. Providers indicate the claim form when they accept Medicare assignment.
Which code is used commonly for DME
HCPCS
What is the purpose of the DMI screen
To check on claims revolving around DME rentals/purchases.
How many steps are there in the claim's lifecycle
6-7 steps
How does electronic claim forms work?
They are completed by the provider and sent to humana through a clearinghouse. Data is then transferred to EHub
Name the four (4) claims statuses
Pended, Denied, Paid, Partially denied
What is a cause code and provide an example
Cause codes are a group of letters assigned by CAS during claims processing that categorizes the reason the services were rendered eg. ILL for illness
What is the PRI screen used for
To check if there are any authorizations attached to the claim
What does Traditional Medicare exist out of?
Part A: Hospital Coverage
Part B: Doctors office coverage
Out of Network providers
What is Cost share Protection
CSP is a Medicaid program that covers the cost sharing for services provided by Medicare plans. When a member is cost share protected, they are not responsible for paying their out-of-pocket share (such as, copayment, coinsurance, deductible). Providers must bill the state Medicaid for the members cost share.
what is an EX code
an EX code is an explanation code , explaining more in detail the reason for outcome
What is the control line for MDI
MDI,MBI,,Firstname,ee,MMYY