Claims Basics
What is a claim?
A claim is a reimbursement request that healthcare providers submit to a member’s insurance program for services rendered.
Which date is used to calculate timely filing?
The date of service (DOS).
What is best practice for verifying member eligibility?
Verify Client ID or SSN first, then name and DOB.
If the ICN is unavailable, how else can you search for a claim?
Client ID and dates of service.
Where are call outcomes documented?
Calls are documented under Notes from the Case tab.
What document reports the outcome of claim processing to providers?
The Remittance Advice (RA).
How many days do providers have to submit an original claim?
At least 365 days from the date of service.
What does TPL stand for?
Third Party Liability
Which interChange menu item is used to find EOB descriptions?
BPA > Related Data
Why is accurate case documentation important?
It supports escalation, audits, and follow‑up.
What are the three most common ways claims are submitted to Health First Colorado?
Paper, batch (EDI), and Provider Web Portal.
How long do providers have to re‑bill or adjust a claim after action is taken?
Within 60 days of the last action.
What does it mean when a member has TPL?
Other insurance must be billed before Medicaid.
Which tab links the current claim to the associated claims previously submitted?
Adjustment Daughter or Mother tab.
What tab lists eligibility errors in Salesforce?
Subscriber Eligibility Errors or Request Eligibility Errors.
What is an Internal Control Number (ICN) and why is it important for claims processing?
The ICN is a unique 13-digit claim number assigned to each claim. It helps identify how and when the claim was received and is used for tracking and researching claims throughout their lifecycle.
How long after Medicare payment must crossover claims be submitted if they do not auto-cross?
Within 120 days.
Who completes prior authorizations for HCBS services?
The member’s case manager.
Where can agents verify whether coordination of benefits exists?
Other Insurance or TPL panels.
What details can you find in the Payment History applet in Salesforce?
You can view payment issue date, payment ID, payment amount, payment method, and RA number.
How do you read the ICN?
RRYYJJJBBBSSS
First two digits are the region code.
Next two digits are the year of receipt.
The next three digits are the julian date.
Next three digits are the batch number.
Last three digits are the sequence number.
What course of action should be recommended if a provider asks about expired timely filing?
Providers will need to request a timely filing override.
How should eligibility be handled for newborns without SSNs?
Use the mother’s member ID plus the child’s name and DOB.
How can you determine the status of a claim (Pay, Suspend, Deny) in interChange, and what do these statuses mean?
Check the claim status field.
Pay means the claim paid in full/part.
Suspend means the claim is flagged for manual review (e.g., duplicate, manual pricing, eligibility issues, timely filing)
Deny means the claim must be rebilled and resubmitted.
How can agents determine if a claim involved coordination of benefits using Salesforce?
Agents can check the “Institutional Other Subscribers” or “Dental Other Subscribers” tabs in Salesforce. These tabs show information about other insurance that paid on the claim, including adjustments made by other payers.