CLAIMS
What do we call the claim form that was submitted by the provider?
UB04
CMS1500
what are the 5 questions you need to ask when quoting benefits?
5Ws
What, Who, Where, When and Why
HSA stands for?
Health Savings Account
What do we call the unique provider identification number?
NPI
NPI Number/ID
This is the main tool that we use when assisting member
Solution Central
What are the 2 types of claims?
Professional and Facility Claims
Tools to cross check the benefits
Where can the member activate their cards?
SydneyApp
Portal Account
To emulate the members online account
Smarthelp
What do we call a claims for a service that was rendered outside the members policy states?
ITS Claims
This is always required to comply every time you are quoting benefits to the member
PBQ - Personalized Benefits Quote
Tools we use to send new card to the member
WCA
A policy that requires to have a primary care physician assigned
HMO
Health Maintenance Organization
To check the image of a submitted claims
WCF
What do we call the 3 claims format for an ITS Claims
SF - Submission Format
DF - Disposition Formation
RF - Reconciliation Format
Give 1 example of a services that is both covered for in network and out of network
Emergency Visit
The only spending accounts that allow the member to still used it even they are not employed anymore
HSA
Health Savings Account
What is the 3 information to confirm the provider network status?
Full name
Address
NPI (Optional)
We use this tool to attach the member submitted claims and send it for re-key
What do we call the process in which the member submitted claim is not showing on the solution central?
Claims Re-key
Rekey
If the member is not aware if the providers network status, what benefits should you provide?
Both in-network and out-of-network benefits
Spending accounts that the member won't be able to use once they left their employer
HRA
Health Reimbursement Account
What is the source of truth for checking an in-network provider?
Provider Task : Research Provider
This is where we can check if the procedure code is medically necessary
OMPTA