Medical
Who handles authorization for Cigna plans with the HCM rider?
What is Cigna?
(Cigna always handles their own authorization)
A provider calls to verify dental benefits. A dental faxback is available, but the member does not have the dental rider. What should you advise the provider?
What is advising the provider that no dental benefits are on file for the member?
While reviewing a claim, you see a billed charge of $250.00 and an allowed amount of $150.00 for an in network provider. What happens to the amount above the allowed amount?
What is it is written off as a contractual adjustment (contractual write off)?"
A provider calls and provides the member's ID number and HIPPA information, but no member record can be located. What should you advise?
What is advising that no member record was found?
(Once the member's name spelling and ID number have been verified and no record can be located, you have completed the required search.)
Luminaire Health administers benefits on behalf of employer groups. Who are the members to those groups?
What are employees and their covered dependents?
Out of network providers generally do not have this obligation that participating providers do regarding contractual write offs.
What is applying a contractual write off?
A provider calls to verify dental benefits, but there is no dental faxback available. What resource should you use to review the member's dental benefits?
What is the Summary Plan Description.
These two resources may contain the address and payer ID needed to submit a claim.
What are the Member ID Card and the SPD?
A provider calls regarding a member and provides the name, date of birth, and member ID E15549456216. The member ID on file has ID E155494156216. The provider cannot provide any additional identifiers if requested. What should you do?
What is advising that the caller that the call cannot be verified and that no member information can be released?
(The caller only has the member's name and date of birth and the member ID provided does not match the member on file. Since they cannot verify an additional identifier, the caller cannot be authenticated and member information cannot be disclosed.)
The provider only has the alternate member ID and provides it along with the member's information. They need assistance verifying benefits. What should you do?
What is assisting the provider, as the alternate member ID meets the same verification requirements as a regular member ID?
This Benefit Repository document is used to verify whether a provider may buy and bill a J-code.
What is the J-Code Blocking List?
While verifying benefits, you see a one thousand five hundred dollars annual maximum benefit with $1,500.00 accumulated year to date. The provider is calling for benefits on upcoming services. What should you advise?
What is advising the provider that the member has met their annual maximum benefit?
What is the timely filing limit for an appeal?
What is 180 days from the date of processing?
A caller claims a member urgently needs care and requests demographic information without completing verification. What should you do?
What is refusing to disclose member information until the caller is properly verified?
What is the speed dial for American Health Holdings?
What is 165?
A provider is requesting coverage information but does not have the service code, diagnosis code or place of service code. What resources can you use to assist?
1) What is the default benefit in Benefit Lookup Tool?
or
2) What is the SPD?
What are the three benefit accumulation codes used to check the Dental Annual Maximum, Dental Deductible and Dental Orthodontics Maximum in accumulations on Family Files?
What are DMX, DDD and DOM?
A provider wishes to continue an appeal through all available levels. Which appeal levels are available to the provider?
What are Levels 1 and 2?
(Level 3 appeals are reserved for members and cannot be submitted by providers)
A search using the member's name and date of birth returns multiple member records. How should you identify the correct member?
What is requesting the member's address or another approved piece of identifying information?
Where can you locate information regarding who the Precertification Vendor is for a member?
What are the benefit rider under the Eligibility tab and the Implementation tab on the Reference Sheet?
A provider is verifying benefits on December 29, 2026 for a service that will be performed on January 15, 2027 under a calendar year plan. What must you do in Benefit Lookup Tool before reviewing benefits?
What is changing the Date of Service in the Benefit Lookup Tool to the service date?
In the eligibility section these two dental indicators distinguish whether we administer the dental benefits or only track them.
What are DEN and DXN?
A member reviews a processed claim and notices that the plan paid $0.00, but the claim was not denied. What happened to the allowed amount?
What is that the allowed amount was applied to the member's responsibility?
(Deductible, Copay or Coinsurance)
There is a claim on file with a date of service of December 15, 2026. The member's plan was active from January 1, 2025, through December 31, 2026, but there was a gap in coverage from December 1, 2026, through December 20, 2026. What happened to that claim?
What is the claim denying due to the member not having active coverage on the date of service?
A federal facility submits a claim beyond the plan's timely filing limit. What happens to that claim?
What is that the claim is processed because the timely filing limit does not apply to federal facility claims?