DUPLICATE/CORRECTED/LATE/VOIDED CLAIMS

CFR Adjustment Process
HPDB
INELIGIBLE CODES
MISCELLANEOUS
100

What number in box 22 (resubmission box) on a HCFA or billed as the third digit of the type of bill on a UB represents a corrected claim?

Answer: 7

100

Outside of adjustments performed after an OI or accident detail update, what documentation procedure is required for all other adjustments?

Answer: Calltrak outlining the claim information and adjustment reason.

100
What tab in the HPDB indicates the timeframe a member has to submit information requested of them for claim processing? For instance, OI or accident detail updates.

Answer: Appeals Tab

100

What ineligible code represents a duplicate claim?

Answer: 902

100
If a claim has already been processed and you need to check to see what edits the claim received initially to ensure it processed correctly, where would you go in CPS to find the edits?

Answer: GJAH

200

What number in box 22 (resubmission box) on a HCFA or billed as the third digit of the type of bill on a UB represents a voided claim?

Answer: 8

200

What procedures do we follow if 25 or more claims require adjustment?

Answer: An Adjustment Project request is ticklered to the OSM followed by a courtesy email to the OSM letting them know you sent the project tickler for their review.

200

What tab in the HPDB is used to identify if UMR handles other insurance updates and how often?

Answer: COB tab

200

A member called in regarding a claim that denied for other insurance. They give you the other insurance update, but after using the appeal calculator it is realized that the member did not supply the information within the plan's appeal timeframe. What denial code would you use for the specific claim they called on?

Answer: 993

200

What is the timely filing limit for Medicaid claims to be submitted?

Answer: 3 years from the DOS

300

When a corrected claim is received and the original claim paid dollars, which claim would be denied as a duplicate?

Answer: Corrected claim

Changes from the corrected claim are made to the original and the corrected claim is denied as a duplicate.

300

A corrected claim was received with additional charges/lines added from the original that was received. The original paid dollars, so we are going to pull back the original to add the additional charges. What code do we add in the “override/adjustment” field on the MISC. tab of HCFA SERVICE ENTRY (450) screen or the HOSPITAL SERVICE ETRY (460) screen to the added lines to represent an adjustment?

Answer: 006

300

If the COB tab in the HPDB indicates that the plan follows the "birthday rule" to determine the order of benefits, what information do we need about the other insurance carrier in order to update the COB correctly?

Answer: Birthday month and day.

If the plan follows the b-day rule, the plan holder whose birthday month and day come first would be the primary plan unless there is a court order mandating something different.

300

What ineligible code represents a claim denied for accident information?

Answer: 998

300

When a claim denies with ineligible code "200", what does this denial generally represent? 

Answer: A non-covered DX

400

A corrected claim is received removing lines from the original claim received, but there is no “7” in the resubmission box on the HCFA. Would we remove the lines per the corrected claim?

Answer: No. We would not consider the lines retracted without the corrected claim indicator of “7”, but would make any other corrections that were submitted on the corrected claim.

400

A call is received from a member regarding a claim that denied for an other insurance update. You update the other insurance tab per the member’s response and adjust the claim. What is the next step?

Answer:  Review the account for any other claims denied for other insurance for all members on the plan and adjust any that are outstanding and within the appeal timeframe.  (if unsure if the OI response was received with appeal timeframe, use the appropriate appeal calculator  within the Appeals/Inquiries PNP)

400

A member called in to see if their plan would cover developmental delays. What tab would you access in the HPDB to find this information? 

Answer: Covered and Excluded Services (D-G) tab.

400

What P&P is used to identify ineligible codes and what they mean?

Answer: Ineligible Codes P&P

400
When a corrected claim is received for processing, what tool can be used to help identify changes from the original claim?

Answer: Claim Compare Tool

500

When a corrected claim is received and the original claim applied to the deductible, which claim would be adjusted to deny as duplicate?

Answer: Original claim

When the original claim applied to the deductible and no payment was made, the original claim would be denied as a duplicate and the corrected claim would be processed.

500

What MUST be done before pulling any claim back for adjustment?

Answer: The claim must be reviewed in depth to ensure an adjustment is truly needed.

500

What tab in the HPDB lists services that may have specific processing instructions or coverage information?

Answer: Special Covered Services/Covid 19

500

We received a call from a provider regarding a claim that is denied with ineligible code "171". They let us know that they sent in the records that were requested for this claim two weeks ago and would like an update. After a review, you locate the records in OnBase. If no review is found, what department would you forward the records to for a "171" denial?

Answer: Claim Consult

500

When receiving a call from a TRH member regarding a claim that has denied for pre-existing and the member states they provided their information to Farm Bureau when they purchased the plan, where and how would we check for those documents?

Answer: Where: OnBase How: Searching by member ID, but removing the first three digits. 

(Example: If the member's ID is 217800650732, you would enter 800650732 in the member ID box to search)

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