Reading EOB
What is PR3?
Copay
If an account needs coding review, which account activity would be used for Coding Review?
AA988
How would you handle a CO97 denial?
(Call insurance to confirm reason for denial if balance is over $200)
-Balance below $200.00 adjust per EOB
-Balance above $200 send to coding to verify. Coding is correct.
-If coding verifies claim is correct, then send to SUP wq to be adjusted.
What is the provider billing form called?
CMS-1500/HCFA-1500
What does Medicare Part A and Part B cover?
Medicare Part A – Inpatient Hospitalization
This part helps cover inpatient care, including:
Medicare Part B – Medical Insurance
This part covers outpatient and preventive services, such as:
What is the unique number for tracking a claim called?
Claim Number
What account activity is used to change the SP level and to what level should it be changed to?
AA93; Change to SP Level 2
How would you handle a CO96/PR96 denial?
-Call to insurance needed to inquire why claim denied as noncovered.
-Depending on insurance response account can be sent to coding, credentialing, or is a non-covered benefit by insurance.
What is in box 32-32B on the CMS-1500 form?
Service facility location
What is the smart phrase to use for entering account documentation?
.INSWQ
What is an EOB?
A document that shows what medical services where billed, what the insurance covered, and what is the patient responsibility.
When the issue is with the secondary insurance, what steps should be taken?
Add account to secondary payer list, document account using 351, and defer for 14 days for follow up
How would you handle a PR288/CO288 denial?
Call insurance to confirm if they have an referral on file if no referral is located in epic)
-Contact insurance to verify no referral is on file for DOS.
- Verify that referral was needed for service processing In Network.
- If referral is NOT on file for DOS and referral was required for in network DOS Adjust balance as no auth write off code 3024
- If claim denied needing referral due to processing out of network (per provider contract) then account to be sent to credentialing.
In what box number will the TID and Invoice number be located?
Box 25 / Box 26
Which payor portal is the most commonly used?
Availity
What is a CO adjustment?
A contractual obligation that is to be adjusted/written off. It is the difference between the billed amount and the allowed amount by an in-network provider.
For homehealth and hospice review, which account activity should be used and what actions should be taken?
AA1530; Add AA1148 to complete from WQ
How would you handle a CO16 denial?
-The CO 16 denial code is a general notification that the claim submitted lacks critical information necessary for adjudication. This could range from missing patient demographic details to incorrect procedure codes or incomplete documentation supporting the service billed.
-If the additional denial code from insurance is not provided then follow up with the payer needed to clarify what information is missing for claim processing.
In what box will the diagnosis and place of service (POS) codes be located?
Box 21 / Box 24B
Which system is used to monitor QA audits?
Verint
What is a CO-197 and how are they handled?
-Contact insurance to verify no auth is on file for DOS.
- Verify that auth was needed for service processing In Network.
- If auth is NOT on file for DOS and auth was required for in network DOS Adjust balance as no auth write off code 3024
For missing insurance payments, what steps should be taken?
- Contact the payer to obtain all payment info needed (Bonus 500 points: Name all of the information that is needed)
- Document account using AA299 with a 14 billing indicator so send payment information to Sup WQ.
- Defer for 14 days for follow up
How would you handle a PR242/CO242 denial?
-Call insurance to verify claim processed OON Per provider contract.
-If the Provider is truly OON then account to be sent to AA 1142 for credentialing.
-If provider is in network and insurance is reprocessing the claim then NRP balances back to insurance bucket with the ref # and reps name in the comment box. Notate and complete account.
- If the insurance rep is sending for review and unsure then defer the account for time rep states review will take.
In what box will the address for the payer be located?
There is no box number for the payer address however it will be located to the top right hand corner of the CMS-1500 form
What sources should be used when working accounts?
Sharepoint and Onenote (WQ Reps may also use Google and Copilot)