Claims & Coverage
This outlines fixed payment rates for services under Medicaid.
What is a fee schedule?
This intermediary routes EDI data between providers and Medicaid and submits the Trading Partner Agreement.
What is a Clearinghouse?
This three-word phrase describes a key goal for every agent’s call.
What is a first call resolution?
Delivery and newborn claims trigger _____ payments?
What is Kick Payments?
When is the use of technical jargon and speaking quickly recommended for effective telephone communication?
What is NEVER?
This term refers to the process of determining which insurance pays first when a member has more than one.
What is Coordination of Benefits (COB)?
This transaction rejection report summarizes the EDI rejections.
What is the BRR report?
Agents should use this feature in CXOne instead of the Hold button during a call.
What is Mute?
There services help people needing daily support for an extended period of time.
What is Long Term Care (LTC)?
This occurs when individuals have assets that exceed Medicaid limits, and they pay for their own care until assets are reduced enough to qualify for Medicaid.
What is Spend Down?
This is the primary purpose of bundled payments.
What is Diagnosis Related Grouping (DRG)?
A surgery claim submission would be submitted using this EDI transaction type.
What is an 837?
This is the type of listening that you should use on provider calls.
What is active listening?
This is how a CSR should empower providers during interactions.
What is educating providers on available tools like the web portal?
Claims set aside for manual review are in this status.
What is pend?
This type of search in the Member tile in VUE360 allows you to search for a DC Medicaid beneficiary with an active lock-in
What is an advanced search?
Which EDI transaction sets are used for a member eligibility inquiry/response.
What is 270/271
This is the Golden Rule of HIPAA.
What is the Minimum Necessary Rule?
This claim status is used when a claim has failed business rules and has not been submitted to the payment process.
What is deny?
This is the number of successful test files PER transaction type that is needed to gain production authorization for X12 Files Exchange.
What is 3?
This part of a medical claim explains special circumstances like repeat procedures or telehealth.
What is a modifier?
A TA1 report is accepted if you see this letter, followed by 000.
What is A?
Name 4 key websites CSRs will need to open every day?
What is VUE360, Workspaces, CXOne, The Well.
This is when a Medicaid beneficiary must use designated providers or pharmacies.
What is "lock-in"?
Collecting data from caregivers is done through this technology.
What is Electronic Visit Verification (EVV)?