Cost Share Jeopardy

SYSTEMS

100

This system is what holds all the documents for our cases

What is Doc 360

200

This is the elgibility system we use for our Cosmos members

GPS 

300

We can pull up the Provider Pick in this granddaddy of all systems

COSMOS

400

We hold all of our caseloads in what Appeals and Tracking System?

ATS

500

This is the computerized claim platform application for Cosmos

CPA (Claims Processing Application)

SRT

100

This is our Case Scenario

Cost Share

200

If the Appellant states they received incorrect information from customer service, vendor, or the provider, what is our next step to refer to?

step 1 Member Appeal One-Time Exception. 

300

There are ________scenarios in the Cost Share Scenario Tab

18

400

If a member is confused about their benefit plan, what step should be do?

Step 3 

Obtain aclaim breakdown.

If all applied correctly, Review additional situations that may apply. If no additional apply, follow the steps for an uphold.

If some applied, Review additional situations that may apply. If no additional apply, follow the steps for a partial overturn of the cost share.

If none applied correctly, Overturn as clerical error and reclassify the case as an OD Reopen.

Justification for Decision: Members cost share was applied incorrectly.Use Outcome Reason: Other Claims Processing Error. For Closure Letter Process, refer to the Part C Plan Reopening SOP.

500

Appellent is appealing a cost share for their colonsocopy.  What scenario step are we going to in the SRT?

Step 11

Step 1

• Review the EOC benefits for all cases.
• Review the Colorectal Cancer Screening section of the Medicare Preventive Services site.
  Note: UHC differs from Traditional Medicare in that if a Screening turns Diagnostic, no copay/deductible will apply as long as the correct coding is appended.
• Determine if the claim billed in accordance with Medicare guidelines.

  Claim billed in accordance with Medicare guidelines

  Claim did not bill in accordance with Medicare guidelines

Step 2

• Review the claim history for the DOS.
• Determine if there are other colorectal cancer screening claims submitted with a -33 or a -PT Modifier, and have no cost share applied.

  Yes

  No

TERMINOLOGY

100

This is a percentage of lesser of billed or allowed amounts, typically. The actual cost share varies from plan to plan.

What is Coinsurance

200

This is the billed amount from the Claim. Also known as the billed amount the provider claims.

What is the Claimed Amount

300

This is the amount that needs to be subtracted from a billed amount to match CMS's allowed amounts.

What is the Disallow amount

400

This is the amount we get after we subtract the disallow and discount from the claimed amount

What is the contracted amount.

500

This is the amount we get after we subtract the member's cost share from Contracted amount

The Payable Amount

DOCUMENTS

100

This documents lets the member know what claims were paid or denied and why. The Date of Denial for member cases is the date they receive their EOB.

The Explanation of Benefit (EOB)

200

This document is a  summary of claim details, payment, and liability UnitedHealthcare sends to the provider with every check. As part of your role, you are required to retrieve and research this for every Post Service Appeal or Dispute.

What is the PRA

300

This is the document is sent to members after a decision has been made to deny in part or whole the payment on a submitted claim to UnitedHealth Care by a provider for services rendered to the member. 

What is the IDN (Initial Denial Notice)

400

This document is the member's policy,  where their rights, responsibilities, and coverage are spelled out in great detail.

What is their Evidence of Coverage (EOC)?

500

This is the document that tells us who our appellant is and their intent of what they want us to do for them.

What is the Initial Correpsondence (Init Corr)

ATS

100

In ATS, in order to move further in your case, you must first start by doing what?

Clicking the Edit icon to get into your task

200

If you have a case that goes up against the timely filing of the case and if you can proceed, what is the task that generates that you need to edit into?

Perform Good Cause task

300

This is the letter generating system that automatically works with ATS

What is NGS

400

This is realtime guidance and recommendations right in your workflow that is integrated within ATS.

What is Case Processing Machine Learning (CPML)

500

If we need to ask our SME a question, what do we do?

Create SME task.