CAS
reflects the amount applied to the individual medical deductible for the period on the MHI screen
What is DED?
PROVIDER CALLS TO SAY THEIR CLAIM DENIED. PROVIDER STATES THEY ALREADY SUBMITTED MEDICAL RECORDS AS THIS IS NOT A DEUPLICATE. WHAT WOULD YOU DO NEXT?
What is CHECK TO SEE IF MEDICAL RECORDS WERE SENT FOR ANOTHER CLAIM WITH THE SAME DATE OF SERVICE
If a provider is rude on a call or uses derogatory comments and you escalate the call, what do you include in the crm notes
what is " the call was escalated b/c of the callers use of profanity"
if a member has active coverage with humana, but is listed as the spouse with another plan who would be primary?
what is "Humana"
advice for a provider that would like a copy of their 1099 tax form
What is send an e-mail to Accounts Payable (AP)
What is basic?
next steps for a provider who hasn't received payment after 30 days, claim has an EX code of 01J
when a provider is challenging the recoupment about a duplicate explanation of remittance and remit/deduct applies, the call should be transferred to
What is " PPI (PROVIDER PROGRAM INTEGRITY"
what not to do when a provider is disputing the home health pricing/claim payment and you determine data elements were keyed in incorrectly
What is transfer to CRU?
system that you can use to see the LCD (Local Coverage Determination" applied to each line of a claim
What is CAS?
the PI field displays this on the MHI screen when a claim has been adjusted
What is 95?
WHAT DOES A REMITTANCE AND DEDUCTION MEAN?
What is "HUMANA WITHOLDING MONEY ON A CLAIM B/C OF AN OVERPAYMENT TO A PROVIDER ON A PREVIOUS CLAIM"
A prov. states they would like a copy of their 1099 tax form. what should you advise the caller?
What is " send an e-mail to account Payable (AP)
primary coverage for Tanner who is a dependent under his mom's insurance (ABC) and under his dad's insurance (XYZ). Mom has legal custody
What is ABC insurance?
what is another name for a fee schedule
What is Provider Contracted Rates?
WHAT MODIFIER CAN BE USED FROM THE MHI SCREEN TO VIEW THE SD FIELD TO SEE WHAT TYPE OF DUPLICATE MIGHT BE IN THE MEMBERS HISTORY
What is "HDR"
WHAT IS THE AVERAGE TURNAROUND TIMEFRAME WHEN SENDING A CLAIM INQUIRY OR OTHER INVESTIGATION TO CRU
WHAT IS " 14-30 DAYS"
how we send cases to CRU when a provider is calling on two different members and both cases need transferred.
what is two cases sent to CRU- One for each member?
location to verify if a claim is already being reviewed by CRU before you route a new case.
What is "case history"
PROVIDER CALLS IN AND STATES THEY HAVE NOT GOTTEN THEIR CHECK AND THEY WANT TO DETERMINE IF A CHECK WAS MAILED TO THE CORRECT ADDRESS. INVESTIGATION SHOWS IT WAS SENT TO THE CORRECT ADDRESS, AND ISSUED LESS THAN 30 DAYS AGO
What is INFORM THE CALLER THAT THE CHECK IS EN-ROUTE TO THEM
modifier used from the MHI screen to view the SD field for duplicate in the member history
What is D?
What is the Process to Convert Multiple codes billed on the same DOS to one all- inclusive code
What is Rebundiling
A PROVIDER CALLS IN STATING THAT THEY RECIEVED A CHECK, BUT NO EOR. THEY WANT TO KNOW THE MEMBER AND THE CLAIMS THE CHECK WAS FOR. WHERE WOULD WE LOCATE THIS INFO?
What is " (ARI) ASSOCAITE REMITTANCE INQUIRY"
guidance when a provider states they have submitted medical records to availity, yet Humana has no record of receiving them
What is contact availity for assistance?
screen will identify either an "N" or a "Y" if a provider is contracted for split billing
What is CFI?