Claim Initiation
Gather Documentation
Determination
Payment
Ongoing Management
100
This is done to initiate claim via telephonic assessment/interview.
What is the "The Intake"?
100
They gather the necessary documentation either direct fax or via vendors.
What is The Administration Team?
100
It mean that entire claim is not approved or not all information have been received for full determination.
What is Partial Eligibility?
100
It acts as a receipt for Dates of Service/bills processed
What is Explanation of Benefits (EOB)?
100
It consist of service center, technical unit and business integrity unit.
What is Support Services?
200
This was replaced by phone calls to file for a claim.
What is the Claim forms?
200
They are responsible for scheduling OSA and obtaining clinical status updates throughout the life of the claim.
What is Clinical Vendor?
200
It is responsible for handling claims appeals (BE or PE denial)
What is the Technical Unit?
200
It must be satisfied before payments made from the policy
What is Elimination Period (EP)?
200
Is responsible for evaluating any care needs change and/or change of providers.
What is Provider Specialist?
300
The person who completes the intake process along with the care managers.
What is an Intake Specialist?
300
They are responsible for helping the insured find care providers in their geographic area and if possible negotiating discounts on the cost of care.
What is CHCS services?
300
The provider specialist review the provider information and makes a determination.
What is Provider Eligibility?
300
The person responsible for processing bills toward EP and/or payments.
What is Benefit Specialist?
300
Is responsible for gathering any documents for CM or PS during the ongoing claim
What is Administration Unit?
400
This is a computer program used by CM team to document the conversation during intake.
What is the Intake Tool?
400
The specific documentation vendor responsible to gather medical records,care providers' information,invoices/bills.
What is Parameds?
400
It is made up of Benefit Eligibility and Provider Eligibility.
What is Determination?
400
It is a documentation proof of care received in the form of invoice/bill.
What is proof of loss?
400
Is responsible for monitoring the PH's clinical status/ BE throughout the life of the claim.
What is Care Manager?
500
This is selected by the CM if claim is viable (i.e. HHC,ALF,ANF).
What is the Claim Path?
500
It is JH's clinical vendor.
What is LifePlans / Nations Care Link?
500
This makes Benefit Eligibility determination after the review of clinical information.
What is Care Manager?
500
It represents a policyholders' care to be counted to either EP or payments.
What Date of Service?
500
Is responsible for the ongoing payment of the claim as well as WOP transactions
What is Benefit specialist?
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