CAS
When you click the CAS claim prefill link in CRM, what screen populates?
A.MDN
B.MHI
C.MDI
B.MHI
Caller is requesting a duplicate EOB or Smart Summary and the orig. is not showing in "CRM RTI" panel, how will you send the duplicate?
Member Claim statement tab- in CRM
What is a diagnosis pointer ?
Information on a claim that links diagnosis to every billed service.
How long is the Timely filling period?
12 Months
What is Cost share protection?
Members who are not responsible for paying copays and coinsurance.
When reviewing a claim is CAS, various MHI screen modifiers with the correct description of what info you will see when you use the modifier.
Member responsibility (K)
Cost share Protection (L)
Financial recovery (CSP)
Provider payment (FR)
Member responsibility -L
Cost share Protection-CSP
Financial recovery-FR
Provider payment-K
Why might there not be and EX code on a claim visible in CRM ?
EX codes are visible in in CRM for paid claims without any errors.
What is the purpose of a code modifier?
To distinguish between types of similar services when the code does not provide a complete picture of the service rendered.
Member calls in and informs you that they have paid for services at their in network providers office and would like to be reimbursed, why can't Humana reimburse the Member , what can we tell them?
Humana can not reimburse members for In network providers.
What is the purpose of the HIVS tool?
The MHI and MDI screen in CAS both provide a Member's claim history information. Which control line would allow you to view all claims for a specific month and Year?
MDI,MEMBERIDNUMBER,SUFFIX,FIRSTNAME,REL,MMYY
Member calls to update their other insurance info. You confirm with Mbr that the other insurance on file is no longer accurate, there is no current open case for cob that is being reviewed, you have captured the OI details in the the Quickstep pre-text fills, what is the next step?
Complete the OI template in CRM
What is an EX code?
Ex codes are three digit alphanumeric codes used to determine the status and resolution of claims
How many claims can be attached to a case when sending to CRU?
One claim per case.
What happens if a member seeks treatment within an impatient hospital or SNF after the benefits has ended?
A new benefit period begins
In CAS, how can you determine if a claim has been reprocessed?
Y is displayed in the ADPY field
How can you quickly access the OI screens in CAS, and what is that screen called?
By clicking the CAS COB prefill link on the plan member page in CRM. The screen is called the CRI screen.
What is the Preadmission Inquiry (PRI) screen in CAS is used for what type of Info?
Inpatient hospital authorizations
Which department should you transfer calls, contacting Humana about accidents?
Subrogation Department
What is a :
Prior AUTH
Pre AUTH
Retro AUTH
Concurrent AUTH
Prior- request to cover medication.
Pre- Request to cover medical.
Retro- After medical procedure has been completed.
Concurrent- When an update or change is needed.
How do you find the ECN ( electronic claim number) in CAS?
Entering the ECN modifier into the CAS MHI screen control line
When is it appropriate to have a preauthorization appeal expedited ?
If the Members life or health is being jeopardized by the delay in care
What two CAS screens do you review for Referral information?
RSI & RFI
Referral summary& Referral file inquiry
Which department should you transfer to if calling in due to being dissatisfied with processing related to claim?
SIU - Special investigations Unit
What must present in present in all claims?
Member identifier- Mbr Id number
Place of Treatment- Urgent care
Procedure code-HCPCS
Date of service- Month, day, year
Diagnosis code-ICD.10