SIU Basics
This department investigates wrongful activity for all of Humana's lines of business.
What is the Special Investigation Unit (SIU)?
SIU takes all complaints or suspicions seriously and does this to questionable claims.
What is investigate them fully?
Claims with this type of pend code may initiate an SIU investigation
What is an SIU pend code?
There are this many ways to determine if a claim is being investigated by SIU
What is two?
Before opening a new fraud concern, review this system's case history.
What is CRM Case History?
This is an intentional deception or misrepresentation that could result in an unauthorized
What is healthcare fraud?
SIU maintains an effective review system to identify these unusual providers.
What are aberrant providers?
Calls from customers reporting suspicious billing practices can trigger one of these.
What is an SIU investigation?
One method for identifying SIU investigations is reviewing these claim codes.
What are CAS claim pended codes?
If a case was already opened or closed, provide the caller with this if permitted.
What is a status update?
What are higher insurance premiums?
Fraudulent activity causes insurers to pass these increased costs to consumers
SIU educates associates, policyholders, and members on the detection of these claims.
What are fraudulent claims?
This department may report suspicious claim practices to SIU
What is CCS?
Another method is checking for this within CRM
What is a CRM Alert?
Advocates should document details of potential fraud, waste, abuse, suspicious activity, and these
What are suspicious charges or situations?
SIU investigates wrongful acts throughout all aspects of this organization
What is Humana?
SIU works with these organizations when dealing with insurance fraud.
What are law enforcement and government agencies?
Verscend and Cotiviti review this type of historical information.
What is medical and dental claims history data?
True or False: Every SIU case displays a CRM Alert.
What is False?
Callers should be informed that the information will be sent to this Humana unit.
What is the Special Investigation Unit (SIU)?
Providers may raise these to cover increasing operating expenses caused by fraud.
What are provider charges?
SIU investigates fraud involving providers, insureds, agents, employer groups, associates, and these people
Who are individuals?
If partners suspect fraud, waste, or abuse, they forward information to SIU with one of these.
What is a unique pend code?
Name one SIU-related pend code: 01J, 0YX, 08, 0J, 0H(, or this code
What is 01!?
Depending on the time of day, callers may be able to speak directly to one of these
What is an SIU investigator?