TERRA
It is a legally required communication our Company sends to members to communicate how their benefits were applied for a service.
EOB (Explanation of Benefits)
HCPS codes are also known as diagnostic/diagnosis codes.
FALSE.
ACCI Stands for?
Agent Assist Claim Inquiry
A document that we need to access before filing an appeal or grievance over the phone.
EOC (Evidence of coverage)
NextGen
What is the timely filing limit for OON provider claims?
180 days for both professional and facility
What are the The 5 Ws of Claims Processing? (In order)
Who, What, When, Where, and Why
Who submits claim if the provider is OON?
Member
An information that should be provided after filing grievance and appeals.
Case ID number or Interaction Id number if there is no CASE ID.
ERISSA stands for?
Employee Retirement Income Security Act
How many days does the mbr or provider have to return the information once ERISA letter is mailed back for additional information needed.
45 calendar days
AEG stands for?
Associate Empowerment Guidelines
An expression of dissatisfaction with an aspect of the organization’s operations or activities, including the actions of network providers and practitioners.
Complaint
TAT FOR URGENT Grievance and appeals
72HRS
An information that should indicated to your notes after checking the document/status on the nextgen for grievance and appeals status
CASE ID number and Necessary information that was provided to member
TAT for claim processing through our system.
30-45 Calendar Days
What is the request that may be needed when a claim is processed incorrectly.
Claim Adjustment
Its a process that has been established to provide consumers, health care providers, and authorized representatives the right to request a reversal of an adverse determination.
Appeal
atleast 1 Service applicable for Surprise Billing Mandate include:
Do we have forms to send to member for written appeals and grievance request
No.
At least 3 types of claim-Related code
Diagnosis Codes
Procedure Codes
HCPCS Codes
Revenue Codes
Modifier Codes
2 ways of submitting claims.
Professional-Electronic
Facility-Mailed
A formal complaint or expression of dissatisfaction made by a member or a member representative, either verbally or in writing, about something that did not involve a prior denial decision.
Grievance
An appeals and grievances pertain to situations that arise before services have been provided to the member.
Pre-Service
An appeals and grievances pertain to situations that arise after services have been provided to the member.
Post-Service