Terminology1
This is the term that is also known as recoupment, the claim payment system automatically deducts overpaid dollars from future amounts payable to a provider or member.
What is Recovery
Funds are removed from the claims allowed amount. This may affect both the provider's paid amount and member liability, especially if their cost share is based on a percentage of the allowed amount.
What is Downadjustment
The original claim shows a check should have issued; however, there is no record of the check going out. It’s been 30+ days from process date.
What is Stop Payments
No matter our scenario, what three documents should we look at to help us determine our findings?
This is the screen we use for Provider Pick
GI205 screen
This term means...The original claim payment is at a lower rate than the correct amount. e.g., Claim was denied or paid zero originally.
The amount the member owes. This can include the deductible, copayment (flat fee) or coinsurance (percentage of allowed amount).
What is Cost Share
The provider's normal rates are called this.
Claimed or Billed Amount
For cost share appeals related to CPT95165, what benefit in the EOC will apply?
The Part B Drug benefit in the EOC will apply. 9this is found in ?Helpful hints)
These three points must match for Provider Pick
fed tax id, npi, and zip code
Box 11 or 11a
When funds are added to a claim's allowed or contracted amount. What is that known as?
What is Upadjustment. This may affect both the provider's paid amount and member liability, especially if their cost share is based on a percentage of the allowed amount.
Claim payment is updated to maintain payment integrity. This may affect the amount the provider is paid or the member's cost share amounts. Claims may be adjusted even if the allowed or contracted amount doesn't change but the percentage of member and provider liability does change.
What is an Adjustment
What is the clue as to WHY the claim was paid, reduced, denied, or adjusted
The Reason code also known as Remark code
What Cost Share scenario is the Appellant is disputing inpatient vs. outpatient cost share
Scenario 4: Appellant is disputing inpatient vs. outpatient cost share
What screen do we verify further for the provider?
GI201 screen-The Provider Mastery screen
The amount UnitedHealthcare pays the provider calculated from the allowed amount minus the member's liability
What is Paid amount.
Also known as the contracted amount, this the amount calculated by the claim payment system using contracts and established fee schedules. It is the amount the provider is owed by both UnitedHealthcare and the member's cost share, which includes deductibles, copayments, and coinsurance.
What is the Allowed Amount
This is the automatic reduction of certain federal spending established by Congress as a budget enforcement tool. The federal government requires that a 2% reduction be applied to claims, and this amount is paid by the provider for each Medicare claim.
What is Sequestration.
If we have an init corr that talks about a colonoscopy, what must we do?
Per SRT scenario step 11...
Step 1
What screen do we use to verify Service code and contract benefit?
CL451 Screen
The provider owes UnitedHealthcare money. This may be a result of an overpaid claim, a special project or a change in the member's cost share amount. The provider is notified via their PRA of their options on repaying this amount.
What is a Negative Payee
Sometimes when a claim is up-adjusted and significant time has passed since the claim was supposed to be paid, UnitedHealthcare may owe interest on the unpaid portion of the claim. The timeline and amount of interest to be paid varies by plan and provider contract.
What is Interest?
When we say something is the patient's liability, what does that mean?
Member is liable...
The amount you may owe under the plan (deductible, copay, coinsurance, noncovered items)
What part of the Scenario Research Tool, tells us what to pull up for our required documentation?
Required Documentation (left side in the blue box)
What needs to be consistent with our COSMOS screens and our claim?
Having the correct DIV.