Claims
Which button should you click after researching the claim to find additional information on the claim?
Load Claim Details button
Where would you find how many lifetime reserve days are remaining?
A bene calls in and wants to know if they have a Part B LEP. What view would you go to in NGD to answer their question?
Premium Summary View
How long does a Bene have to file an appeal?
120 Days from the Date they Received the MSN.
Mary Allen needs help paying her part b premium. She let us know that she is single and gross income is $1222 a month. What program may she qualify for?
Medicaid
What date range should you use when searching for a claim?
30 DAY RANGE
How long is a benefit period?
It starts when the bene is first admitted into the hospital and ends when they have been out 60 days in a row.
A bene calls 1-800-MEDICARE. They were in the hospital for a surgery from April 3, 2024, to April 11, 2024. How much is the bene responsible for paying?
Part A deductible - $1,632
Follow the instructions on the MSN.
What script helps us determine what extra help program a bene may qualify for?
Applying for Low Income Assistance Script
MSN Message
$505.00
A bene calls in and want to know when can they have their next colonoscopy. Where in NGD can you find this information?
Preventive Service View
A been calls 1-800 MEDICARE on May 15, 2024. To check the status of their appeal MSN is Date April 6 2024. Their appeal will most likely be in which phase?
Level 1: Redeterminations
Who would the beneficary contact if they had concerns about how they are treated at a SNF?
Beneficiary and Family Centered Care Quality Improvement Organization
A bene calls in about a claim. He states his medigap policy didnt cover his coisurance even though he met his deductible for the year. Where would we go to see if his crossover has been set up?
Other Insurance View
Ben Sampson calls on May 19 and tells you that he received a Medicare Summary Notice (MSN) showing that Medicare paid $98.42 for a visit to a doctor’s office on Feb 4. Mr. Sampson tells you that he did not visit his doctor’s office then. Which script would you access to begin researching Mr. Sampson’s claim?
Medicare Fraud and Abuse Script
Yes, because Medicare covers mammograms once a year the bene doesn't have to wait until the exact day just the month.
A bene received a Medicare Redetermination Notice and wants to know more about it. What should you do?
Ask Probing Questions and then answer his questions.
A bene expresses that they need help understanding what financial help they may qualify for but need assistance in person. Who would you refer them to?
SHIP
A bene calls in to Medicare. She says that she received a bill for a doctor’s visit on July 11, 2023, and is confused about what she needs to pay. Where in NGD would we go to answer her questions?
Claims View
Mr. Sampson says that he recognizes the doctor listed on the MSN. He also says that he called his doctor’s office 2 months ago and was told that his claim would be corrected and resubmitted to Medicare, but nothing has been done. You follow scripting to help Mr. Sampson and tell him to allow the provider more time to resubmit the claim. Mr. Sampson is not happy with that answer. What does scripting instruct you to do?
Transfer the call to a Claims Tier 2 CSR
*3 Day Hospital Stay
* Referred By Physician
*Enter the skilled nursing facility within 30 days of being discharged from the hospital.
Quality of Care Complaints
Allen Green needs help paying her out of pocket expenses for Medicare. He let us know that he is married and joint gross income is $2500 a month. What program may he qualify for?
Extra Help also Know as SSI