HOS
What types of claims fall in this queue?
Hospice
What is the remark code on the claims in this queue
PTRH
T/F County does not accept Electronic COBs
True
If COB is not listed on the member's file in Aldera, what should be done?
Move the claim to COBSEG
What does OIC stand for?
Other Insurance Company
What is the REV CODE on claims in this queue?
658
T/F - If a member has a hip replacement on file, they get 10 visits before an auth is needed
False
Which remark code should be added when County will not pay additional benefits on a COB claim?
CB
CMS-1500 COB claims are processed at what level?
Line level
On the PCF file, which column will have the information needed to enter in the Illinois State File Report?
LTC Provider ID
Which Excel spreadsheet will need to be used when processing Hospice claims?
PCF
How many visits are allowed before an auth is required when there aren't any joint replacements in history?
6
What does in the PR All field?
Primary Carrier's allowed amount
What is remark code should be used when County's allowable is more than the primary carrier's paid amount?
PE
A0426 and A0428 are emergent or non-emergent codes ambulance claims?
Non-emergent
When processing HOS claims, how many sites will the adjudicator need to use in addition to Aldera?
2
What series of CPT codes is used for Joint Replacements?
Z96
What goes in the PR app field?
County's allowed amount
T/F - When checking to see if an EOP is attached to the claim, the adjudicator needs to review the View Rendered Form
False
When reviewing claims in the DRG/SOI workflow, which digit in the DRG number indicates the severity of the illness?
3
What is the formula for Hospice claims (when manually pricing)
Allowed amount x 95% = ____ - amount on the PCF
T/F PT rules are per calendar year
False - per lifetime
UB claims are processed at which level when processing?
Claim level
When processing a UB claim with COB, which lines will the adjudicator process the COB info?
The room & board line
If the Nursing Facility is a County Facility (i.e. DeKalb County Rehab and Nursing) then the Adjudicator will use this Rate List to determine the facility’s rate
County Nursing Facility Payment Rates