Verifying Eligibility
Coordination of Benefits
EMR/Claim Correction on Portals
Mid Level Providers
General Questions
100

Name 3 of the 7 different types of plans offered by MassHealth.

Standard

CommonHealth

CarePlus

Family Assistance

ConnectorCare

Premium Assistance

SafetyNet/Limited

100

Name the website that we use to check eligibility for almost any payer.

Experian

100

Name the basic info you need before going into the EMR.

Provider Name

DOS

What was the procedure

100

Name the payers that require a modifier be added to each charge on behavioral health claims.

MBHP

Carelon

100

Recently there was an occurrence of something that only happens every 4 years.  What was it?

Leap Year-February 29th.

200

Name the behavioral health carve out plan payer for Cigna.

Evernorth

200

Name the people you email when you place a file in the Printing folder that needs to be printed and mailed out.

Anita Fetherman

Anabolena Jordan

CC-Kristina and Bethany

200

Explain why you would receive a denial w/ a CARC code of PR-16-Lacks information submission error and a RARC code N4-Missing/incomplete/invalid prior Insurance Carrier EOB.

The payer believes they are secondary and they need the primary carrier's EOB to correctly process the claim.

200

Name the list that tells you a what payers a provider is in network and where can you find that information.

Payer Participation Lists and they can be found in Teams under the Teams Icon

200

What is one fun fact about you?

Thanks for sharing!

300

True or False- When finding other payer information on Medicare's portal. You do not have to check eligibility on that new payer's portal or Experian. 

False-You always need to check eligibility for the new payer you found to make sure they agree.  Otherwise, the claim will be denied and you back where you started. 

300

When splitting insurance payers due to a change in coverage what date do you enter as the effective date in Expanse? Is it the DOS or the date the policy became effective?

The date the policy became effective.

300

On the Medicare Portal- which button do you click to submit a corrected claim? Would it be Initiate a Clerical Error Reopening or Initiate Redetermination

Initiate a Clerical Error Reopening

300

Name the only payers that we cannot bill charges for mid-level providers?

Medicaid

Medicaid PCC

300

What is Medicare? 

Government funded insurance for Seniors and people with disabilities.

400

In mPower, where do you check to see what AR Flags you need to action when documenting the work you did in Expanse.

The little red flag icon-hover over it and it will show you which ones to action.

400

Where do you go in Expanse to move a balance to a different bucket? 

Process TXNs tab then Edit Balance at the bottom.

400

In the EMR, how can you see more reports for other DOS or providers? Ex. An Operative Report from 2023

By clicking on the little plus sign in the More Reports column

400

What do you change the charge amount to when a claim for a Mid-Level Provider is paid by Medicaid PCC?

$.01

400

What does EMR stand for?

Electronic Medical Records

500

You have a CARC 27 denial-Expenses incurred after coverage terminated from TuftsMCD. You check eligibility on the MassHealth portal and it says the patient had CarePlus on the DOS. Who do you bill? 

If when you click on the date range next to CarePlus and it shows a different MCO listed you would check eligibility for that payer.  If active, you would bill that payer.  If no MCO is listed, you would bill MCD (MassHealth) using their policy number starting with 100.

500

You receive a denial PR-108-Rent/purchase guidelines were not met from BCBS.  What are they really looking for?

EOB from the primary payer.

500

You need to send medical records for a knee replacement.  The charges are from an assistant surgeon. What report would you send?

The Operative report that was created by the lead surgeon.  Assistant surgeons do not write a separate report. 

500

How do you refund a payment made to a mid-level provider on the Medicaid portal?

Find the claim on the portal and click on the ICN you want to refund. Click Void at the bottom.  **Remember, when you void the claim on the portal you are voiding everything on the claim.  If you need to refund just one line, then you would do a corrected claim.

500

What is a deductible?

The amount a patient needs to pay before their insurance benefits begin.