Medical
A provider sends information to Humana asking to be paid for their services. This request for payment is called...
A claim
The mentor used for pharmacy denials and next steps
Actions for RxNova Error Codes
21Y
Administration is denied due to no corresponding vaccine
this denial pops up for duplicate claim
023
The secondary system we use to view Claim details, if not CRM.
CAS
This denial status code means Unfinalized denied claim, denied due to errors
70-DNI
062
Routine foot care not covered. Member responsibility.
090
Submit Claim to Primary payer
This is the screen we go to in CAS to view a member's other medical insurance information.
Per step 2 of Pharmacy Claim Research, what information should you gather when doing the research? Name at least 3 pieces of information.
04@
Services/supplies not reasonable/necessary - LCD/NCD applied. Provider disputes that claim was billed correctly per Medicare guidelines. No further info on mentor about LCD applied on claim.
This is the denial for Exceeds Quantity Therapy Allowed
151
This is is the practice of providers billing patients for covered services over the insurer's contracted or allowed rates
Balance Billing
In some circumstances, the member may pay for the prescription and needs reimbursement. What is this referred to as
Pharmacy Direct Member Reimbursement
also acceptable: Direct Member Reimbursement or DMR
08A
Medicare explanation of benefits (EOB) needed.
080
Claim in Error - RTS
Name at least 3 pieces of information needed to file or Submit a domestic claim
Member ID
Member's name
Provider's name
Provider TAX ID
Provider NPI
Diagnosis (DX) codes
Procedure codes (CPT or HCPCs)
Billed charges and dates of service
Place of treatment
If applicable, revenue codes
This is the BIN/PCN for an MAPD plan. This is provided to pharmacies, sometimes, to process claims.
- Bank ID Number: 015581
- Process Control Number: 03200000
08J
Authorization for services denied
171
Repackaged drugs are excluded by the plan