Enter Title

Basics

100

Types of Insurance plans 

HMO , PPO , EPO ,POS , FFS  , CDHP

200

Provider networks ?

In network and out of network 

300

The treatment provided to patient is coded as ?

Procedure code 

400

The health issue  / disease of the patient is codes as ?

Diagnosis codes

500

POS 11,21,22, 12  IS ?

Office , inpatient , outpatient , home 

CIW

100

Under which tab do we get  provider billing NPI ?

Provider details tab

200

Under which tab do we get standalone pricing  ?

search --> pricing  

300

Under which tab do we get NDC code details  ?

Claim Lines  -- click on the line to chk the NDC code 

400

under which tab do we get bill type or frequency of the claim ?

Claim header tab

500

Under which tab do we get clinical editing details  ?

Editing 

WGS

100

Which popup provides additional diagnosis codes and modifiers ?

HP , PD  

200

Which screen in WGS provides procedure codes for facility claims  ?

DS POPUP -- F8 screen

300

Under which popup do we get ambulance pickup and drop zip code ?

DS Popup

400

What is the navigation for standalone screen ?

Shift f3--f9--f4--enter--enter

500

under which screen of wgs do we get account # , check # details  ?

EOB screen  

SCENARIOS

100

Provider is asking why is the claim denied ?When reviewed  , we see the claim is denied for benefit .what is the right course of action ?

advise on denial and raise gi

200

Claim is in 51 status and provider is asking why is the claim still pending ? what do we check  ?

check if we have sccf . If yes  ,open the sccf and see if sf is open or open adjustment . reply accordingly 

300

Claim is processed recently and check status is not available , which check issue date is forthcoming  . what do we reply ?

provide claim pay details and tell check is forthcoming 

400

Claim is denied for eligibility 0706 and in history we do not have claims after dos which is paid . what do we do  ?

raise 105 GI and ask confirmation of denial 

500

Claim is denied for 1298 . Provider states approval is not required  . what do we do  ?

Raise a gi 152 and ask for confirmation  

SCENARIOS

100

Claim is denied for auth . Provider submitted medical records and is asking to reconsider  , what do we do ?

verify the PHI and attach in 168 for review  

200

B2 has open mrr . Provider submitted records . what do we do ?

attach the records under open mrr 

300

Par Provider submitted appeal and claim is denied for not medicallynecessary  .what do we do  ?

attach the appeal in 306 for review

400

Records where attached in open mrr and been more than 30 days , since we received determination . what is next ?

raise 174 GI for determination

500

claim has 172 sccf and provider submitted 25 pages of same records for second time . when we check the 172 sccf , records are already attached and is within 30 days . what is our action ?

verify the second set of records and if exact dup to the first set , we will reply back telling its a dup record and also tell the previous records are still in review .