Medical
What takes precedence when there is a conflict between plan information?
The Summary of Plan Document (SPD)
What does the abbreviation DMX stand for?
Dental Maximum
What does EMP PAY, on the claims tab mean?
That the payment will be issued to the member.
They call for dental benefits but there is no DEN or any other dental rider on file, what does that mean?
That the member does not have dental benefits.
Is Luminare Health a Insurance company?
NO, Third party administrator (TPA)
What is the tool used in dynamics to check for benefits?
The Benefit Lookup Tool (BLT)
Can we fax dental benefits?
(Not a yes or no question)
Only for plans with a dental faxback.
How many characters are in the claim number?
11
What happens if you do not verify HIPPA on a call?
You auto fail your QA, (A financial penalty may applied for violating HIPPA)
What does the suffix 01 usually mean on a Id card mean?
That the person is the subscriber.
What Document Type should be selected on Benefit Repository when looking for the J‑code blocking list?
The Other Document Type.
How are orthodontic claims paid?
Monthly or Quarterly.
When a claim is sent for review how many days should you advise?
None you should advise, 30 to 45 business days.
What is needed to verify HIPPA on a call?
Member Id
Members Full name
Member DOB
(Sometimes the Members Address)
What does timely filing mean?
It is the time period allocated to file a claim.
What would you need to obtain to be able to verify benefits?
The Service code(Procedure name), The diagnosis code and the Place of Service code.
What does the abbreviation DOM stand for?
Dental Orthodontics Maximum
What is the provider responsibility for an in network claim?
It is the providers contractual write off.
What does the DXN rider mean?
That the member has dental benefits that is administrated separately (COBRA Tracking), (Generic Tracking) and (Different Administrator exp: Delta Dental).
Who would handle the authorization services for Cigna policies.
Cigna
How many characters are in a service code?
A service code is 5 characters long.
If the provider ask for a service that is not on the faxback how would they obtain the benefit?
They should submit a pre-d.
What is the amount a member must pay out of pocket for covered services before we begin to pay benefits?
The Deductible
If a group is terminated would we be able to process claims and issue payments.
No, of course not.
(Only correct answer any other variation of no is wrong)
How would providers obtain the EOB for their claim?
They can obtain it from "providerpayments.com" utilizing the claim number and the draft number