Claims Basic
What is a Claim?
A provider request to humana for payment of services rendered
what is a CMS-1500?
The Claim form used for physician and diagnostic services.
The cas screen where claims detail are viewed
Insurance approval required before some services are received
What are encounter claims?
Claims submitted by capitated provider identified by payee code e or i
What is 12 months from the date of service?
The maximum time a provider generally has to submit a claim
what is UB-04?
The Claim form used for hospital -related services
What is MDI?
the cas screen used to search for claims not found in crm
What is a Referral?
A Type of Authorization that allows a member to see a specialist
how long can a skilled nursing facility benefit period last?
100 days
what are paid, denied, or partially denied?
The three possible outcomes when a claim is processed
What is an ICD-10 Code?
The Diagnosis Code Commonly Found on claims
The cas screen used for benefits accumulation
Who is a Primar care Physician?
The physician who usually initiates a referral
What is the claims rework unit (cru)?
The department that review incorrectly processed claims
what is CAS?
The system that assigns a claim Id when a claim is inventoried
What are Procedure Codes?
CPT,HCPCS, AND REV codes
What is CAS CLAIM PREFILL?
the crm shortcut link mostly commonly used to access claim information in cas
What is a Network Deficiency Waiver?
A waiver allowing out-of-network providers to be paid at in-network levels when access standards are not met.
What is the grievance and appeal department?
The department handling appeals of claim decisions and pre-authorizations
what is 30 Days?
Humana Must generally pay or denied a claim within this many days of receipt.
What is code editing Logice?
These help identify billing irregularities and incorrect combinations of codes
What is HIVS (Humana Image View Station)?
This Application stores scanned paper claims and correspondence
What are letter of agreement, continuity of care, and transition of care?
. pre-service exception processes that may allow out--of network treatment at in-network benefits
What is the Claims cost management/Subrogation team?
Theam team responsible for reviewing accident-related claims to ensure humana is not paying when another entity should.