Claims Submission
What are 2 ways providers can submit claim forms?
Submit by paper, claim forms electronically
What is a Claim?
A claim is a invoice to Humana by the provider after a member receives medical care.
What is the difference between clean VS dirty claims?
Clean claims are error free claims the first time they are submitted for processing. Dirty claims non clean claims can be filed multiple times.
What are the 4 claim statuses?
Paid, pended, partially denied, Denied
What is a CPT Code?
Used by physicians and other healthcare providers to define what was done or given to a patient
When a claim is submitted electronically where can it be viewed?
eHUB
What is preventive care?
Is the practice of getting regular checkups, screens and Immunizations to prevent or detect the disease early.
What is Medicare Assignment?
Medicare assignment describes the fee structure that providers agreed to be paid by Medicare for their services.
Where can we find the appeal rights on EOB?
At the bottom of every Humana EOB
What is an ICD -10 code and what does it look like?
Defines the patient's condition or illness, Three-t0-five-digit
alphanumeric code
What is the UB-04 claim form used for?
This form is used to submit hospital and /or ancillary services
What is diagnostic testing?
When the Dr. is testing you for a symptom or health issue.
What happens if a provider does not except Medicare assignment?
Provider can bill the member
What is an EOB?
it is a document that explains how the charges are processed, is not a bill.
What is a HCPCS code and what does it look like?
Used by Durable Medical Equipment (DME) suppliers and Home Health Agencies (HHA) to define what was done or given to a patient.
(Five-digit alphanumeric)
What is the CMS-1500/ HCFA-1500 claim form used for?
To submit standard health insurance from vendors and Physicians
What is Therapeutic Care?
refers to treating an illness or curing a condition.
What is a 1-year limit exception?
it is the unique submission with a few exceptions for inpatient, emergency services, nature disaster, COB, corrected claims
What can include a EOB?
Total charge, plan discounts, plan/benefit exclusions, Plan paid, your share.
What is an REV code and what does it look like?
Used by hospitals and Skilled Nursing Facilities (SNF) to define what was done or given to a patient. (Three-to-four-digit number
(most with leading zeros)
What is a super bill?
This type of claim is used when we have several providers and services that belong to the same group.
What is Code 78306
CPT code Bone and/or joint imaging. whole body
What happens when a caller does not agree with a timely filling denial?
A appeal is required with proof of timely filing for review consideration.
What is a explanation of remittance?
It is a notice of payment and/or adjustment sent to a provider
What is a Place of Treatment (POT)?
Defines the setting where a service was provided