Claims 1
EOB stands for ____________
Explanation of Benefits
MARS stands for ______________
Medical Audit and Review Solutions
OCE stands for __________
Outpatient Code Editor
Aside from the DOS, billed amount and Tax ID number, what else is needed to check the denial reason in MARS?
Patient's last name
According to the Centers for Medicare Services (CMS), a New Patient is a patient who has not received any professional services, i.e., E&M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within ___________.
The previous 3 years
What tool is used to check if the code/s billed is/are bilateral eligible?
Knowledge Library or KL
TAT for INN and OON for initial claim processing
INN: 60 calendar days
OON: 30 calendar days
Tool used to check if the claim was received and has been successfully adjudicated.
ECHO
What is needed from CPA>Physician Full Claim to see the timeframe for DME rentals?
DME Cat Code/Cd
EFT stands for ______________
Electronic Fund Transfer
DME By Member Incident Detail
VCP stands for _________
Virtual card payment
Claim is in development and is in the adjudication system. What's the status?
Pending
PRA stands for _____________
Post Remittance Advice
All reviews are completed, and claim has gone through Check write. What's the status result in Spire?
Finalized
What option in Doc360 are you going to select to pull up the claim image?
Claims & Correspondence
In CPA, under DME by Member Category Search, aside from the DME cat code, what other information is required?
Medicare ID
LCD and NCD stand for __________
Local coverage determination and national coverage determination
If Medicare ID is not auto-populated in DME by Member Category Search, in what section in Spire can you locate the Medicare ID?
Policy Details
TIN/NPI: 1043278351 | Member ID: 982474221
Claim #: 08852312 | Div: KEN
DOS: 04/25/2024 | Billed amount: $415
What's the exact denial reason?
This patient received care by provider 1427374305, 1558346338, 1427374305, 1558346338, 1558346338 on Line ID KEN22157175001, KEN27357242001, KEN31128861001, KEN82806643001, KEN85932384001, Claim ID KEN22157175, KEN27357242, KEN31128861, KEN82806643,
Deborah's claim got denied for not meeting the coding standards. In order for the decision to be overturned, what would you recommend?
Abdul calls in because his claim was denied due to exceeding the rental capacity. He insists that the DME is needed by the patient and the claim should be paid. Given that the network status is in-network, what would you advise?
Submit a reconsideration/first level of appeal along with the copy of complete medical records to prove medical necessity.
TIN: 330377113 | Member ID: 991559170
Claim #: 00320758 | DOS: 2/5/2023 | Billed amount: $ 1156
What's the exact denial reason?
Based on Medicare coding and payment standards, external ECG scanning component (code 93247) may only be reported once in 15 days since the code definitions includes more than 7 days up to 15 days of monitoring. 1 units of service for external ECG recording were reported between 01/23/2023 and 02/05/2023. Note that this edit is dependent on information reported in claim(s) 22302936. (Source: CPT code definition)
Sam's claim was processed as OON. The claim was denied due to not meeting the NCD/LCD criteria. He mentioned that he coordinated that the claim was billed correctly and a corrected claim is not an option. What would you advise?
Submit an appeal within 60 calendar days from the denial date.