Denials
Insurance/E-Billing
State Specific
Terminology
Misc.
100
What does denied for compensability mean?
The claim was never accepted by the carrier. The carrier may indicate the claim was denied as it was not work related.
100
Name 2 insurances on the standard billing address list? (Auto or WC)
Arrowpoint, Broadspire, Chartis, Claims Management, C.N.A., Copperpoint Mutual, Esis, Employers, US DOL, Gallagher Bassett, Hartford, Liberty Mutual, Pinnacol, Pinnacle Risk, SWIF, SXC, Texas Mutual, Tristar, York 21st Century, All state, Encompass, Farmers, Geico, High Point, Liberty Mutual, Nationwide, NJ Manufacturers, NYC Transit, Palisades, Progressive Auto, State Farm, Travelers, USAA
100
What state has a Supportive Care Award?
Arizona
100
What does MMI mean? Briefly describe MMI.
Maximum Medical Improvement, An assessed condition of a claimant based on a medical judgement that the claimant has recovered from the work injury to the greatest extent that is expected.
100
Where do you find all the documents pertinent to verification?
On the L Drive in the Verification Folder
200
What does denied for liability mean?
There is a question on who is responsible for this claim. Examples would included: There could be several insurance companies involved and they are trying to determine who is responsible, The claim could have been reported incorrectly to them by the employer or the employer could have had a lapse in coverage, or the claim has settled with no ongoing medical.
200
Name 2 website that we can use to look up adjuster contact information?
Farmers, Geico, Travelers, NYSIF, Zurich
200
Which state does the VSS fax pre-auth requests to on a daily basis?
Louisiana
200
What is another term for "Controverted"?
Disputed/Litigated/Denied
200
Name 2 insurances that are on the Verification Do Not Call List.
IWIF/Chesapeake, Consolidated Benefit Resources, Comp Source Oklahoma, LUBA, Beacon Mutual, NYC Law, Gray Insurance
300
When verifying a workers comp claim, which denial reason would you choose if no other denial reason describes the situation the adjuster explained?
Unrelated site
300
Does IWP send bills electronically to Tmesys?
Yes
300
Which state do we ask if health insurance is primary for auto claims?
New Jersey
300
What is a compound medication?
The combining, mixing or altering of ingredients to create a customized medication for a patient. They are recognizable in our system as the NDC codes with start with a '999999...'
300
How does IWP earn Extreme Days?
2/3 goals must be met (Enrollment new patients, prescriptions filled by pharmacy and cash collections
400
If the adjuster tells you the claim is denied, does IWP discontinue shipping medications to the patient?
IWP will continue to fill medications through the dispute process as long as the patients attorney is pursuing the claim (Unless it is a NY or DE claim)
400
Does IWP send bills electronically to Health E Systems?
No.
400
What must you do when you become aware that a claim is a Federal Claim?
Email Senior VC or Supervisor to override billing to Federal.
400
What is an IME? Breifly describe an IME.
Independent Medical Exam It is a medical evaluation that documents a workers' condition.
400
On a reverification for workers comp, if a claim is on settle/hold on the case and claim screen, how would you process the template?
Denied, liability with notes in the overview regarding the settlement information and process the template as “bad”
500
What does denied for indemnity benefits mean?
The carrier is denying wage payments.
500
Can IWP bill private health insurance directly if a claim is denied?
No. IWP does not bill private health insurance directly.
500
Name 2 states that we do not have to email the Auto RC's on when we become aware of a denial reason, such as no coverage, funds exhauseted, no policy and so forth?
NJ, NY, PA, MA & MI
500
What is a Statute of Limitations?
A law which sets out the maximum time those parties have to initiate legal proceedings from the date of an alleged offese.
500
If a claim is labeled as “Dispute” on the case and claim screen, how do you process the template?
Fill in the questionnaire the best you are able, note the overview the LC is working the claim and process the template as “Good”
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