What's that called?
What's this do?
Name that Form
How long do I have?
100
Providers submit this form to bill for payment of services that do not require prior authorization.
Claim/TAR Form
100
True or False:
The same form can be used to request payment or authorization.
True.
The Claim/TAR form can be used to bill for completed procedures (that don't require prior authorization) or used to request authorization for future procedures.
100
This is what type of document?
A Notice of Authorization (NOA)
100
A provider has this long to return an RTD response
45 days
200
This form is in response to a Claim/TAR Tracer
Claim Inquiry Response (CIR)
200
A Claim Inquiry Form (CIF) can be used for these two things.
Re-evaluation (for payment) of billed services that were denied or modified on an EOB.
or
As a Claim/TAR tracer to follow up on documents after 30 days
200
Resubmission Turnaround Document (RTD)
200
A Notice of Authorization is valid for this long.
180 days
300
Providers use this form to request authorization for treatment
Claim/TAR form
* without date of service or rendering provider NPI
300
This document is sent to providers if more information is needed for final adjudication.
Resubmission Turnaround Document (RTD)
300
This is called a__
Claim Inquiry Form (CIF)
300
Documents are processed in this order
first in first out
400
This form tells providers if a requested treatment was approved, denied or modified.
A Notice of Authorization (NOA)
400
Providers can do these two things with a Notice of Authorization (NOA)
Bill for payment of authorized services.
or
Submit for re-evaluation (for authorization) *Once
400
This was submitted as a ___ *note the highlights
Claim
400
A provider has this long from the most recent EOB date to send a Claim Inquiry Form (CIF)
6 months
500
This kind of date is included in the document control number.
Julian Date
500
The sixth and seventh digit of a DCN tell you this information
the type of document ( these are called the document identifier types)
500
This was submitted a
s a __ * note the highlights
Treatment Authorization Request (TAR)
500
Providers have this long from the end of the month treatment was performed in to bill for payment.
12 months.