TRANSFERS
MEMBER IS HAVING KNEE PAIN AND DOES NOT KNOW WHAT DOCTOR TO SEE
NURSE TRANSFER
TPL INDICATOR WHEN BCBS IS THE PRIMARY PAYER OR MBR HAS NO OI
1/BA
THIS INELIGIBLE REASON CODE IS USED WHEN THE CLAIM IS DENIED WHEN MEDICAL RECORDS ARE REQUIRED
360
A statement sent by your insurance carrier that explains which procedures and services were provided, how much they cost, what portion of the claim was paid by the plan, and what portion is your liability, in addition to how you can appeal the insurer’s decision.
EXPLANATION OF BENEFITS (EOB)
MEMBER IS ASKING YOU TO VERIFY WHAT ADDRESS THEIR ID CARDS WERE MAILED TO
BLUE STAR
MEMBER IS LOOKING FOR INN PROVIDERS AND BENEFITS FOR FAMILY COUNSELING
YOU ASK A MEMBER IF THEY HAVE OI, AND THEY INDICATE THAT IT IS MEDICARE OR MEDICAID. WOULD WE UPDATE COB SOLUTIONS?
NO
CHECK MPUI/BS TO VERIFY IF THE INFORMATION IS ALREADY INPUT
F4 (QUALITY CHECK)
THE AMOUNT YOU OWE FOR HEALTH CARE SERVICES BEFORE OUR HEALTH INSURANCE OR PLAN SPONSOR BEGINS TO PAY ITS PORTION
DEDUCTIBLE
MEMBER CALLING IN WITH a CPT CODE AND WANTING TO KNOW IF A PRIOR AUTHORIZATION IS NEEDED
HAS ACCOUNT GUIDE OR CODE CHECK
MEMBER CALL IN REGARDING ASSISTANCE WITH STRESS MANAGEMENT, COUNSELING SERVICES AND DEPENDENT CARE RESOURCES
EMPLOYEE ASSISTANCE PROGRAM (EAP) OR HEALTHIFY
MEMBER IS A ACTIVELY WORKING AS A SUBSCRIBER ON ONE PLAN, AND HAS ANOTHER PLAN WHERE THEY ARE A RETIREE. WHICH PLAN IS PRIMARY?
PLAN WHERE MEMBER IS ACTIVELY WORKING
THIS FIRST SCREEN HAS THE MEMBER (PATIENT) AND SUBSCRIBER (POLICY HOLDER) DATA. THIS DATA CAN BE CHANGED IF NEED BE.
GEEP (ELIGIBILITY)
THE MAXIMUM AMOUNT THE MEMBER PAYS FOR EXPENSES COVERED UNDER PLAN DURING A DEFINED BENEFIT PERIOD
OUT OF POCKET MAX
MEMBER CHECKING PREAUTH STATUS ON A SPECIALTY DRUG
ARIS OR SMART UM
MEMBER GOT DIAGNOSED WITH A CONDITION AND NEEDS ASSISTANCE WITH GETTING A SECOND OPINION TO CONFIRM THE DX
GRAND ROUNDS
WHAT IS THE COB CLAIM STATUS WHEN A CLAIM IS PENDED FOR COB
50/50
WHAT FUNCTION ON YOUR KEYBOARD WOULD YOU USE TO BACK OUT OF A CLAIM?
F3
A FIXED DOLLAR AMOUNT THE MEMBER IS REQUIRED TO PAY FOR COVERED SERVICES AT THE TIME THEY ARE RECEIVED
COPAYMENT
MEMBER SENT IN AN APPEAL OVER A MONTH AGO AND IS INQUIRING ON THE OUTCOME
ACE > CLAIMS & APPEALS SUMMARY > APPEALS TAB
OUT OF STATE MEMBER NO LONGER WANTS COVERAGE THROUGH THEIR EMPLOYER, AND IS LOOKING FOR OTHER PLAN OPTIONS THROUGH BCBS
RETAIL LINE (FOR THE SPECIFIC STATE THEY RESIDE IN)
PATIENT IS SPOUSE ON ONE PLAN AND DEPENDENT CHILD ON THE OTHER PLAN. WHICH RULE WOULD APPLY?
RULE 6. LONGER/SHORTER COVERAGE RULE
THIS SCREEN ALLOWS YOU TO REVIEW THE CLAIM INFORMATION AND ALLOWS YOU TO PAY, PEND, FINALIZE OR INCREMENT A CLAIM
GCLR (CLAIM RELEASE)
THE MAXIMUM AMOUNT A HEALTH CARE PLAN WILL REIMBURSE A DOCTOR OR HOSPITAL FOR A GIVEN SERVICE
ALLOWED (ELIGIBLE) AMOUNT
MEMBER GETS DENIED FOR A CT SCAN AND ASKS YOU TO REVIEW THE DENIAL LETTER THEY RECEIVED
EVICORE