G/A
Appointment of Representative = Is a person authorized by the member the person that acts for the member for healthcare purposes
Where are a member claims located in CRM?
The claim summary page accessed from quick link on the policy member page
How can you locate the denial code explanation if it's not listed in CRM?
MTV and CAS EX Codes Guide OR Searching via Mentor codes in search bar
What does the CCM/Subrogation department do?
Investigates claims paid by Humana that are identified as accident and injury related. Subrogation also reviews claims denied as work-related when a dispute arises.
What are benefit accumulations?
- Deductible
- Out of Pocket
- Lifetime Maximum
What are the ways a grievance or appeals can be submitted?
Verbally, online, by mail or fax
Logged information can be viewed where in a case?
Logged events can be viewed from the Case Tracking tab of the case in the Logged Information or Process sections.
What is the name of the tool used to determine the provider’s participation status and if there are potential errors in the processing of the claim?
CAS POST PRV VERF EDGE in Digbot
Why is place of treatment (POT) important?
Determines how a claim pays
i.e. a member may have copayment for office visit but coinsurance for outpatient hospital visits
True or False
If the member has cost share protection, they do not have to pay their balance bill, even if the provider is allowed to balance bill them
True
True or False
The timeframe of 72 hours to resolve a verbal expedited appeal begins at the time of the call with the CSS.
False
Begins once the appeal is received within the Grievance and Appeal department
What is Cost Share Protection & where can you locate if a member is or not?
Cost share protection means the member cannot be billed for cost share- copays, deductibles, or coinsurance
Debut, The Dual Status 12 Month Flag side panel link in CRM, Plan Member page view the Special Needs Plan (SNP) field, MRI Screen CSP Modifier
Per the mentor Claim Processed Differently Than Expected what mentor do you follow for lack of preauthorization or referral issue?
Claim Penalty or Denial for No Preauthorization or Referrals Calls
Members can view the status and processing determination of claims where?
via their MyHumana account
What does a Notice of Adverse Benefit Determination letter inform the member of?
A Medicaid or LTC claim that was entirely or partially denied, Reduction of hours or services, or Denied authorization
What is the decision timeframes for standard and expedited Medicare G&As?
Standard- As expeditiously as required based on the member's health but no later than 30 calendar days after the receipt date
Expedited- No later than 24-72 hours (Depending on state) after receipt of all the required information of the initial request
Where would you verify if other insurance is listed with Humana system?
CRM>Plan Member page>Plan Information>Other Insurance field>Yes goes to Other Insurance Details. OR CAS COB Prefill
What is Claims Cost Management (CCM)/Subrogation phone number and extension?
866-444-1771 EXT 1390055
What are the three pre-service exceptions allowing OON providers to be considered in-network?
LOA-Letter of agreement
COC-Continuity of Care
TOC-Transition of Care
Why might you have to research the specialty of the provider associated with claim submission?
if there is a question about the copay amount
What is the name of the mentor used to locate guidance for second, third and fourth level reviews for Medicare appeals?
Appeal Guidance for Medicare
What would be the case routing for CRU for Integrated Plans?
• Service Center: Louisville
• Department: Medicare Claims Research Unit (CRU)
• Topic: None
What information does CAS Screens MHI, MDI, and MAI display?
MHI- Retrieves 1 specific claim processed on a member
MDI- Locates claims using month and year for a member
MAI- Displays the accumulation history information for a member or plan by a specific month and year
What ways can a member submit a claim for a Medical DMR?
Download form humana.com, request hard copy to complete via EMME letter ME2798 OR mail receipt with required information to return address on back of Humana ID card
What is the timely filing deadlines for IL, MI, and SC? (Hint. This info is found in an excel from a mentor overview)
IL-MMP/duals, Medicaid and IL FIDE D-SNP/Integrated (eff1/2026) = 180 days from DOS
MI-Medicaid, MI HIDE D-SNP/Integrated(eff 1/2026) = 12 months/1 year from DOS
SC-HIDE D-SNP/Integrated(eff 1/2026), Medicaid 1 year from DOS
*Retro elig-6 months from date member added to mcd system no later than 3 years from DOS, SC