CLAIMS
THE NUMBER USED TO TRACK AND PROCESS CLAIMS.
DETERMINES WHICH PLAN HAS PRIMARY, SECONDARY, OR TERTIARY LIABILITY.
WHAT IS THE ORDER OF BENEFIT DETERMINATION RULES?
THIS SYSTEM CAN BE USED TO VIEW OUT OF AREA CLAIM INFORMATION.
WHAT IS BLUESQUARED?
THIS IS WHERE YOU VIEW DOCUMENTS EXPORTED FROM EMULATOR B (FLDR).
WHAT IS IMAGE?
This letter is sent to members to advise members of the processing of a claim and what they may owe.
What is an EOB?
APPLIED WHEN ONE PLAN COVERS A PERSON AS A SUBSCRIBER AND ANOTHER PLAN COVERS THE SAME PERSON AS A DEPENDENT.
WHAT IS RULE 1? (NON DEPENDENT/DEPENDENT RULE)
THIS IS THE TAB WHERE WE CAN SEE OI IN BLUESQUARED.
WHAT IS OPL?
THIS SYSTEM IS WHERE YOU CAN USE YOUR COST ESTIMATOR.
WHAT IS BLUE ACCESS FOR MEMBERS?
THIS LETTER OF THE ALPHABET IS DESIGNATED TO FOLLOW THE DCN OF A CLAIM THAT WAS SUBMITTED BY A MEMBER.
WHAT IS 'C'? (PAPER CLAIM, LOOSE BILL)
APPLIED WHEN THE INDIVIDUAL IS COVERED UNDER A COBRA PLAN AS A MEMBER/EMPLOYEE/SUBSCRIBER AND ALSO COVERED UNDER AN ACTIVE PLAN AS A MEMBER/EMPLOYEE/SUBSCRIBER.
WHAT IS RULE 5? (CONTINUATION OF COVERAGE RULE)
THIS IS THE ORDER OF COMMUNICATION FORMAT BETWEEN THE HOST PLAN AND HOME PLAN.
WHAT IS THE ORDER OF SF, THEN DF, AND THEN RF?
These requests will be handled as required by law and are put in place in situations where a member requests an address change and a more limited distribution/increase protection of PHI because it will endanger them.
WHAT IS A CONFIDENTIAL COMMUNICATION REQUEST? (CCRF)
THIS LETTER OF THE ALPHABET IS DESIGNATED TO FOLLOW THE DCN OF A CLAIM THAT WAS ELECTRONICALLY SUBMITTED BY THE PROVIDER.
WHAT IS A 'X'? (PROFESSIONAL CLAIM)
TRUE OR FALSE. WE ENTER MEDICARE INFORMATION INTO COB SOLUTIONS TO UPDATE OI TAB.
WHAT IS FALSE?
THESE 2 THINGS IDENTIFY A BLUECARD CLAIM, BUT ARE NOT INCLUDED ON AN IN-STATE CLAIM. (EXCLUDING PEARL PLANS)
WHAT IS A SCCF NUMBER AND A 'H'?
When a BIT47 is present on a code you will need the type of pre-service request done.
Pre-Determination
THESE 4 TYPES OF SERVICES ARE COVERED UNDER MEDICARE PART A.
WHAT ARE INPATIENT HOSPITAL STAYS, SNF FOLLOWING AN INPATIENT HOSPITAL STAY, HOME HEALTH/COORDINATED HOME CARE, AND HOSPICE CARE?
WE COORDINATE BENEFITS WITH THESE 5 GROUP HEALTH PLANS.
WHAT ARE:
-GROUP POLICIES WITH A COB PROVISION
-STUDENT MEDICAL POLICIES
-AARP
-DIRECT-MARKET QHP POLICIES FOR MT, NM, OK, AND TX COORDINATES BENEFITSWITH OI POLICIES TO INCLUDE GROUP POLICIES
-NON HCSC DIRECT MARKET QHP POLICIES THAT CONTAIN A COB PROVISION
?
THIS IS THE PLAN CODE FOR THE STATE OF IL.
(RESEARCH REQUIRED)
WHAT IS 121/621?
THIS INELIGIBLE REASON CODE IS USED TO INDICATE THAT A CHARGE IS A DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM.
What is IRC 129?
THIS WAS PASSED BY CONGRESS AND ENACTED THE 2% SEQUESTER AMOUNT ON CLAIMS PAID OUT BY MEDICARE.
What is the Budget Control Act of 2011 (BCA)?