Claims
This is a medical claim form used by individual doctors & practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics.
What is CMS-1500
The are statements that show our members the medical care we pay for, services we don’t pay for and why, and any charges they may owe.
What are Explanation of Benefits (EOBs)?
A claim number ending in 02, 04, etc, has gone through this process.
What is adjustment?
To search for a pharmacy claim, you will first search for the member in this system
What is RxClaim?
Rx prior authorizations are housed in these two systems
What is RxClaim and PAHub?
This claim form is used by hospitals, nursing facilities, in-patient, and other institutional/ facility providers.
What is CMS-UB-40?
To determine the print date for an EOB, use the ninth digit of this subscribers number
What is social security number?
This adjustment is used when the claim information is inaccurate, and the provider’s office indicates the correct information by phone.
What is Par Provider Consent to Change?
In RX claim, The Sts column indicates what status the claim is in. This letter means the claim has been cancelled.
This system Lists approved prior authorizations.
What is RX claim?
This field lists the amount we paid to the facility after deducting member cost share.
What is The Prorate/Prorate (Facility Paid)?
This is a process for professional providers to determine if Blue Cross will cover the cost of a proposed service before treating the patient.
What is prior authorization?
These claims have been rejected because of errors.
What are rejected claims?
When looking at an RX claim, this is the section we read from on the price table
What is the approved column?
This system Displays all prior authorizations.
What is PA hub?
To calculate our approved amount for facility claims, these are the two sections we add together
What is prorate paid (facility) and member liability?
Some plans have this, which allows deductibles to carry over from the last 3 months of the previous year to the current year.
What is fourth quarter carryover?
The first letter in a rejection code identifies its general rejection type. Generally, letters B, E and M/U, which stand for these
What are benefits, eligibility and maximum related rejections?
This section in RX claim shows the cost share for a claim that applied to totals
What is accumulator info?
A Medical Necessity Authorization, also known as a benefit or Drug List exception, is used when either of these are applicable
What is a drug is not covered and member is requesting a waiver for a Mandatory MAC sanction?
This type of Adjustment is a system adjudication code that overrides system logic and a total manual process including calculating and applying all cost share to the claim.
What is 54?
This task is used to research any claims that applied to deductible, coinsurance, or out-of-pocket limits
What is View Totals?
NCompass offers these three claim adjustment processes:
What is simple adjustment, transfer to SCIP, and transfer to Claims Ops?
These types of drugs are made from 2+ ingredients mixed and dispensed as a single product by a pharmacy.
What is Compound and/or Multiple ingredient co?
This type of authorization covers cases where a drug needs a quantity override
What is prior auth?