Claims FAQ
This means that the claim has not finished processing. Claims have up to 30 days to fully process.
What is PEND status?
A Provider needs to be added to the provider mailing list, they should be transferred where?
What is enrollment?
This will be used when a provider is calling about the status of their claim (denied, paid, etc.).
What is Claims?
Where to find a member's date of death
What is go to member > summary > date of death.
When we see Edit 135 we...
What is Follow the configuration steps and escalate accordingly?
Claims that are in a PAY status have not moved fully through processing yet.
What is PAY status
A provider says they updated their address and it's still not showing correctly, they should be transferred to
What is PNM?
This contact code will be used when an EVV provider is experiencing technical issues.
What is Technical Issues
How do I find the member's living arrangement?
What is go to member > attributes > living arrangement.
Edit 101 Means?
What is No Active Contract?
Providers have up to 365 days after the date of service to submit claims.
What is timely filing?
A Provider needs to report fraud, warm transfer them where?
What is enrollment?
This will be used when a provider is calling about the status of their authorization (denied, approved, etc.).
What is Financial Inquiry?
How do I know if a member has restricted coverage?
What is go to member > benefits > eligibility. You will want to expand the carat next to the member's active plan and click Restriction?
No contract term found for service is Edit...
What is Edit 150?
Who's Payor ID 0007610?
What is UHC?
A provider needs to know their affiliation, where do you go?
What is go to provider > affiliations.
This will be used to check the eligibility of a member (plan, effective, and term date).
What is Eligibility?
What if a member has Part B Premium, do we pay?
What is we will not pay any coinsurance, copays, or deductibles. *This is also referred to as SLMB.
What do you do if you see a claim denying for No COB amount on claim?
What is? If we see a claim denying with this edit, please check the member's primary insurance. If the member has active Medicare or external enrollment for the services being billed, then this is a valid denial. Medicaid is the payor of last resort, therefore primary payors must be billed first.
What to do if a claim is paying $0, but there is a PA on file
What is Navigate to the CPT Services > find the CPT code that is not paying > expand the carat > and check your manual pricing.
Where do you check to see if a provider is active/enrolled in network?
What is go to provider > provider pricing?
This will be used for missing ERA/835.
What is EDI?
How do I find the member's cost share?
What is go to member > cost share?
If a Claim Requires Ordering/Referring...
What is: If we see a claim denying with this edit, in most cases it is considered a valid denial?