Payment Cycle Playbook
This is the main purpose of weekly payment cycles in Medicaid.
What is ensuring compliance with timeliness requirements and maintain provider participation?
The number of providers listed on the RA report.
What is 1?
Agents can search and view vendor payments and provider records from this system/ screen.
What is the Finance Tile in VUE360?
This is an overpayment or reversed claim resulting in excess funds received by the provider.
What is a credit balance?
The Finance Department does not perform this function. (Choose one.) What is:
What is "Reviews and corrects claim errors?"
This is the day of the week that the Payment Cycle for health care claims begins.
What is Friday?
This is the function of the Remittance Advice (RA) in Medicaid claims processing.
What is “explaining payment decisions and adjustments to providers”?
This is a Provider or organization who receives payment from the District.
What is a Vendor?
This is the legal obligation of third parties (such as private health insurance, Medicare, or other liable entities) to pay for medical services before Medicaid does.
What is Third Party Liability (TPL)?
This is used to send escalations to Finance.
What is a notification in Verint?
Providers must submit health care claims by this day and time.
What is by 3pm on Friday?
BONUS! Are these statements TRUE or FALSE?
DHCF, official state Medicaid agency for D.C., covers over 40% of D.C. Residents.
Both are TRUE!
These are the two categories of provider repayments for the District.
-Monthly Payment Plan
-Standard Payment Plan
Identify the primary, secondary and last payer if a Medicaid Beneficiary is hospitalized after a car accident and has Employer-sponsored health insurance, Auto insurance with medical coverage, and Medicaid coverage.
Who are
This information is included in an escalation sent to Finance via Verint.
What is information such as claim number, amount in question, research steps, etc?
This report is run every Thursday to identify payments that have not yet had checks issued.
What is the Payment Reconciliation Report?
This is the information found on a Remittance Advice. (List as many items as you can.)
What are
This claim status means that the claim has to wait for the financial cycle to process.
What is WAITPAY or WAITDENY?
One reason Medicaid would pay since Medicaid is the payer of last resort.
What is:
"the other insurers deny the claim or their coverage is insufficient?"
These are common areas of focus for Centers for Medicare & Medicaid Services (CMS) Medicaid audits. (Select all that apply)
A. Eligibility verification
B. Claims accuracy
C. Financial integrity
D. Marketing strategies
What are:
A. Eligibility verification
B. Claims accuracy
C. Financial integrity
This is the correct next step when a payment has been pending for 15 days without a check issued.
What is “Escalate to the Office of the Chief Financial Officer (OFCO)”?
This is when an RA generates. (Choose one.)
What is “when the provider has claims included in the payment cycle”?
This is generated when the Claim moves to PAY or DENY, and notifies the provider of payments and adjustments.
What is the Remittance Advice (RA) 835/820?
The number of days Providers have to dispute Medicare disallowance.
What is 30?
(If the provider does not appeal within 30 days, it is unlocked and reversed.)
When there is a credit balance, an automated Accounts (a)_______ invoice fixes the credit balance and an Accounts (b)___________ invoice gets the money back from the Provider.
What are:
(a) Payable?
(b) Receivable?