Claims
Clinical Edits
Surgery
Appeals and Grievances
COB
100

The tab within claims inquiry that holds the payment information and details.

What is the "Remittance Tab"?
100
The definition of a clinical edit.
What is a system denial due to incorrect coding and bundling and payment of certain CPT codes?
100
The benefits quoted for an outpatient surgery.
What are the surgery/anesthesia (surgeon) benefit and the outpatient surgery (facility) benefit?
100
What a member would submit (appeal or grievance) if they disagreed with a prior authorization denial.
What is an appeal?
100
The department that the COB team is a sub-department of.
What is OFT?
200

The reason why CL 150363954100 denied. *BONUS: Whose responsibility does it fall to?

What is "BAM - No AIM Prior Auth Obtained"? *BONUS: Provider Responsiblity

200
The line that line 6 is denying to on CL 152804301300.
What is line 5?
200
The age a member needs to be to have a screening colonoscopy covered-in-full. (For members on an individual plan or non-grandfathered group plan)
What is 50+?
200

The number of levels for an appeal that a fully large member has access to.

*BONUS: What are the levels for?

What are 3 levels?

*BONUS:

Level 1 - Member writes in

Level 2 - Grievance committee

Level 3 - IRO (external)

200
Whether or not the provider needs to submit their claim twice to Providence for a dual PHP member.
What is no?
300
The tab within claims inquiry which shows the second disallow explanation code applied to a claim.
What is the "Disallow Amounts Tab"?
300
What the provider can do for a CE denial of u16 that they disagree with.
What is rebill with a correct diagnosis code?
300
The modifiers billed to indicate it is an Assistant Surgeon claim.
What are modifiers 80, 81, 82 and AS?
300
The different ways a member can submit an appeal.
What are by mail, email or fax?
300
The information to obtain and route to the COB team for updates.

Look at the KMS scenario: Sending a CSI to the COB Team :)

400
The place of service code for 21.
What is "Inpatient Hospital"?
400

What the provider can do for a CE denial of z58 that they disagree with.

What is submit a clinical edit inquiry fax form?

*BONUS: What 2 things do they need to send with the form?

400
The charges/claim that an Additional Cost Tier copay applies to.
What are the professional charges?
400
The amount of time that PHP has to respond to a member's first level appeal.
What is 30 days?
400

The COB methodology used for all plans on the commercial team.

*BONUS: Explain what it means.

What is the post-mandate method?

*BONUS: The insurance companies coordinate benefits to reimburse the provider at the highest of the two contracted rates.

500

What we call the money that we keep for providers on a risk contract.

What is withhold?

500
The national network that does not have to submit a clinical edit inquiry form for clinical edits listed in KMS that they disagree with?

What is PHCS/Multiplan?

*BONUS: What would you do if a PHCS/Multiplan provider called about a CE they disagree with?

500
The reason why CL 170674699600 applied to member responsibility and was not covered-in-full.
Why is the member under the age of 50?
500

The amount of time that PHP has to respond to a member's expedited appeal.

What is 72 hours? (NON business hours)
500

The place you would find notes from the COB team about a members coordination of benefits.

Where is Member Notes?
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