Claim Hodge Podge
This tab in a claim in VUE360 provides a summary of a claim's editing and adjudication.
What is the Edits tab?
This determines if you will clear Edit 913 from claim.
What are operational requirements?
If there are thousands of claims with enrollment status changes, this process should be run.
What is Auto Adjustment?
These are some of the benefits of DPA.
What are?:
Increases operational efficiency
Enhances quality and compliance
Supports cost reduction and process improvement
Improves process performance
Meets service goals
If thousands of claims need enrollment status changes, this process should be run.
What is Auto Adjustment?
Step Edits are accessed under these tabs under the claim in VUE360.
What is Edits-->Step Edits?
For Edit 302, you will do this if you add an attending provider to the CEF claim and receive an error that the provider is not found.
What is add a memo to the claim and deny the claim?
A claim status of WAITPAY or WAITDENY means this.
What is that the claim has to wait for the financial cycle to process?
These are changes to a previously processed claim without fully reversing the claim and its payment.
What are claim adjustments?
This type of claim has codes that do not match or are invalid and may have missing information, such as patient date of birth or beneficiary ID.
What is an unclean claim?
Claims that require manual pricing will enter this phase.
What is suspended claim phase?
For Edit 301, you will do this if the date of admission on the CEF claim is blank.
What is edit the claim in CEF?
This is your next step with Edit 187 if the Service Code is 58951 and a blank Consent for Sterilization Form is attached to the claim.
What is add a memo and deny the claim?
Auto Adjustments are run here.
What is in the Utilities section of Administrator?
If more than 10 claims are affected by Edit Code 6004, this group will run the Auto Adjustment process.
Who is Shared Services?
Doing this to a finalized claim prevents reversals and adjustments from being created.
What is locking the claim?
For Edit 203, if the procedure code/CPT code and revenue codes listed on the paper claim match the claim in CEF, you will do this.
What is deny the claim?
If you review a claim with Edit 217, and the paper claim shows a DOS of 2/5-2/15/25, but the CEF claim shows a date of service of 2/6-2/16/25, this is your next step.
What is data correct the information in CEF to match the paper claim and then adjudicate the claim?
This was a temporary increase in the federal share of Medicaid costs that states received under ARRA.
What is Enhanced FMAP?
This process is triggered when beneficiaries are updated with Retro Medicare.
What is the Medicare Disallowance Process?
If a procedure code D150 pends for edit code 224, and D150 was paid to the same provider 6 months ago, this action should be completed on the claim.
What is the claim should be denied?
You will begin researching Edit 168 with these steps.
What is by checking the Date of Service (DOS) of the paper claim against the DOS of the CEF claim?
When reviewing Edit 204, you should do this if the Value Code shown on the CEF claim shows 81 with covered days of 6, but the paper claim image shows 80 with a covered days of 7.
What is update the Value Code and covered days and revalidate the claim?
For Edit 224, if the claim is dated 8/7/25 and has procedure code D0150, and you see that this procedure code was previously billed for the beneficiary on 7/1/23 and paid on 9/5/23, you would do this.
What is OK the claim?
This is the day on which Medicaid funds will be recouped if a provider chooses not to appeal the recoupment of funds due to Medicare Disallowance.
What is the 31st day?