Basic Knowledge 1
What is an ex code?
EX Codes are three-digit alphanumeric codes used to determine the status and resolution of a claim.
Which department handles all reviews for potential accident related claims?
Claims Cost Management (CCM)/Subrogation
For a variety of reasons, a claim may need to be reprocessed.
In CAS, how can you determine if a claim has been reprocessed?
Y displays in the ADPY field
What is a referral?
A type of authorization that allows a member to be referred to a specialist.
How are most medical claim related calls documented?
Creating a case in CRM using the logging feature
Why would a provider need to send a corrected claim to Humana?
The initial claim contained an error.
When sending multiple claims to Claims Rework Unit (CRU) for review and possible reprocessing, how many claims can be attached to a case?
One case per claim. If there are three claims needing review, 3 cases must be created.
Who handles a caller reporting an accident to Humana?
CCM/Subrogation
This tool can be referenced for claims involving older plans or as a back-up if DEBUT is not available.
Benefit Grids
When billing members, in-network providers and out-network providers accepting Medicare assignment are not allowed to:
Balance bill
Which authorization is done after medical services have been received?
Retrospective Authorization
What is a Network Deficiency Waiver?
Exceptions are based on areas of the country where an access standard for a specific list of provider specialties isn't met.
If a caller is informing you they have claims on file for services they did not receive, who do you transfer the case?
SIU
Dual eligible members who qualify for cost share protection are not responsible for paying _______________ of covered expenses.
their deductible, copay, or coinsurance costshare
A claim submitted with a global surgical fee modifier includes what charges?
All surgical related services from the operation date through a specified number of days
The PRI Screen in CAS is used for what type of authorizations?
Inpatient hospital admissions only
True or False. If a claim is from an in-network provider, payment cannot be sent to the member.
True
What does the PI code in CAS indicate for an adjusted claim?
The reason for the claim adjustment
Which code on a UB-04 form is the same thing as the Place of Treatment or Place of Service?
Bill Type
Which code assigned during processing categorizes the reason services were rendered?
Modifiers
What is the purpose of the Humana Image View Station (HIVS) tool?
HIVS is an application that stores scanned images of correspondence received by Humana.
Which supporting department handles reissuing member payments for checks with a void, outstanding, stop payment, or escheat status?
Provider Payment Integrity
When you click the CAS Claim Prefill link in CRM, which CAS screen will display?
MHI
The PRI Screen in CAS is used for what type of authorizations?
Inpatient hospital admissions only
A procedure code changed during the claim adjudication process to more accurately match the ICD-10 diagnosis is an example of ___________.
Global billing
Code editing logic