What's the deal with claims?
What's the difference between Pre-service and Post Service?
Pre-service= Services Not yet rendered.
Post service= Service has been rendered.
Where will 224 PCR IRU route an ORS to?
Single Adjust
What section of the SOP would we go to determine if a project should be created?
ETS Case Entry - Other Information
Name the 5 (ALWAYS) member liability scenarios Gabe put on his Liability slide.
1.ONN 2.OI/OIM/OIMEDI 3. PreService 4. Member or Member Rep submitted 5. DEA with no claim on file
What does FWAE stand for?
Fraud, waste, abuse and error
What will be on your claim in ISET and Unet that tells you it has coordinated with other insurance or Medicare?
OI, OIM or OIMEDI
What ORS address do you route New Claims to?
103 IRU CLM
What screen would you find the "Create new case for same project" box in ETS?
Case Resolution Screen
When you have an INN claim with the HR remark code, it is always member liability. True or False?
False, only if there is also money in the Not Covered field
For commercial policies, what are we routing to 550 FRD SSA?
NOTHING!!!!!
What are some items you can find in NDB if you have your provider's TIN?
Place of Service State. Provider's Contract. Provider's Address. Provider's MPIN. Provider's NPI
If you get a Admin SharePoint issue for EMPIRE, what ORS address do you send it to?
012 IRU APL
ERISA are to be entered as Projects. True or False
False
If a Par provider is appealing for the Deductible on a claim, what would be the liability for the case?
Member Liability
What type of review are you looking for if placing a check mark in Case Development in PICTS?
Initial Review
How do you look up the closure code behind a 7Y in Unet?
Use the Macro Cntrl+Shift+L or on your MHI screen insert the letter L in front of your draft in your control line.
What address would you be routing policies 690100, 46000, 23111, 107300, 00001 if you want to send to Single Adjust?
100 ADJ ADJ
If you have the same member but multiple providers with different liabilities, should you enter as a Project?
No
If a Par Provider is appealing for Bundling of codes on claim, what would be the liability?
Provider Liability
What's an Optum application used for FWAE claims by E&I Appeals?
PICTS
Would ICN ED95481190 be entered as Admin or Clinical in ETS?
Clinical - The HR line is sanctioned and in ISET you see the EY remark code is in Reimbursement Reduction field
Why would we route an ORS to 250 ADJ HJV?
You have a True Harvard Pilgrim with no Reconsideration done
Other than ERISA, what other scenarios wouldn't be entered as a project?
Multiple issue types and categories submitted together/
Submission contains both first and second level appeals/
Complaint and appeal submitted together/
Submission contains both reconsiderations and first level appeal/
Submission contains both medical and pharmacy/
Issue includes both member and provider liability concerns.
What if the Par Provider comments are unclear, what would be the liability?
Provider Liability
When using the DDD calculator what state do you use to determine the Optum Due date?
Member's state of residence