Terms
What term do we use to describe when a member is covered by more than one insurance policy
COB ( Coordination of Benefits)
A provider calls to as if Cpt code 78815 is covered and does it require a prior auth. What would your answer be?
Yes it is covered and requires auth from nia ( Evicore)
Claim # 17072H976700 what type of denials are these
Claims XTEN denials
This place of service code reflects services rendered in an Ambulatory Surgery Center
24
False
What do we call healthcare providers that contract with Horizon NJ Health, who agree to treat our members and accept our payment as payment in full
In-Network
MLTSS covers non traditional services such as ( choose all that apply)
Vehicle or Home modification
Chiropractic services
Laboratory services
Chore services
Vehicle or Home modification
Chore services
Claim # 17285H683400 locate the claim in Facets and DMS. Is there an EOB attached to claim? Was it processed?
Yes the claim processed and paid correctly. There is no EOB attached because an EOB was not required.
This place of service code is used when services are rendered in the emergency room:
23
What are the five main types of coding systems?
ICD-9,ICD-10,CPT-4, HCPCS, Revenue Codes
If Medicaids allowed amount is LESS THAN primary carrier's paid. Medicaid Pays Zero. If Medicaids allowed amount is MORE THAN the primary carrier's paid, Medicaid will pay the lesser of the total member liability of the difference between the medicare paid and Medicaid allowed amounts.What does this describe?
Lesser of Logic
What service would not require a Medicare Eob due to it being a COB exclusion:
Medical day care
inpatient hospital stay
non routine office visits rendered by a par specialist
none of the above
Medical Day Care
Yes we paid this claim correctly.
This code consists of three digits, is located in the upper right hand corner of the UB04 and defines the place and type of service for a facility claim:
Type of Bill
315.75
These codes consist of two digits and are placed on professional health care claims to indicate the setting in which a service was rendered.
Place of Service
Which services would be included in MLTSS EOB exclusion:
Home Delivered Meals
Vehicle or home modification
sick visit to PCP
none of the above
Home Delivered Meals
Vehicle or Home Modification
Claim ID 16134G547200 in facets. the provider wants to know why the last two lines of the claim were denied. What would you advise the provider?
86901 was denied correctly for no auth and 86850 denied correctly for services being capitated to another provider.
Which of the following is considered critical claim data:
Patient Name, ID#, and DOB
Provider Tax ID, NPI, and Taxonomy #s
Coding( Cpt-4, HCPCS, ICD-10)
None of the Above
Patient Name, ID#, and DOB
Provider Tax ID, NPI, and Taxonomy #s
Coding( Cpt-4, HCPCS, ICD-10)
Which service would require an Auth from UM?
Inpatient Hospital Stay
ER visit at a par hospital
X rays rendered in an ER setting
None of the Above
Inpatient Hospital Stay
Medical Coding
Medicare pays, then MLTSS
Only Medicare pays
Only MLTSS Pays
none of the above
ONLY MLTSS
A provider calls regarding a claim deneid for EOB from primary. the provider did not realize that the member had other insurance. Looking up Member ID # 70793234 what other COB coverage exists for this member ?
Facets claims will reflect different claim statuses, depending on where they are in processing phase. Which claim statuses allow us to provide payment and denial reasons to the provider.
Status code 02, Status code 01
Original NOn cob claim subissions must be recieved within
180 days from the dos.