DUPLICATE/CORRECTED/LATE/VOIDED CLAIMS
What number in box 22 (resubmission box) on a HCFA or billed as the third digit of the type of bill on a UB represents a corrected claim?
Answer: 7
Outside of adjustments performed after an OI or accident detail update, what documentation procedure is required for all other adjustments?
Answer: Calltrak outlining the claim information and adjustment reason.
Answer: Appeals Tab
What ineligible code represents a duplicate claim?
Answer: 902
Answer: GJAH
What number in box 22 (resubmission box) on a HCFA or billed as the third digit of the type of bill on a UB represents a voided claim?
Answer: 8
What procedures do we follow if 25 or more claims require adjustment?
Answer: An Adjustment Project request is ticklered to the OSM followed by a courtesy email to the OSM letting them know you sent the project tickler for their review.
What tab in the HPDB is used to identify if UMR handles other insurance updates and how often?
Answer: COB tab
A member called in regarding a claim that denied for other insurance. They give you the other insurance update, but after using the appeal calculator it is realized that the member did not supply the information within the plan's appeal timeframe. What denial code would you use for the specific claim they called on?
Answer: 993
What is the timely filing limit for Medicaid claims to be submitted?
Answer: 3 years from the DOS
When a corrected claim is received and the original claim paid dollars, which claim would be denied as a duplicate?
Answer: Corrected claim
Changes from the corrected claim are made to the original and the corrected claim is denied as a duplicate.
A corrected claim was received with additional charges/lines added from the original that was received. The original paid dollars, so we are going to pull back the original to add the additional charges. What code do we add in the “override/adjustment” field on the MISC. tab of HCFA SERVICE ENTRY (450) screen or the HOSPITAL SERVICE ETRY (460) screen to the added lines to represent an adjustment?
Answer: 006
If the COB tab in the HPDB indicates that the plan follows the "birthday rule" to determine the order of benefits, what information do we need about the other insurance carrier in order to update the COB correctly?
Answer: Birthday month and day.
If the plan follows the b-day rule, the plan holder whose birthday month and day come first would be the primary plan unless there is a court order mandating something different.
What ineligible code represents a claim denied for accident information?
Answer: 998
When a claim denies with ineligible code "200", what does this denial generally represent?
Answer: A non-covered DX
A corrected claim is received removing lines from the original claim received, but there is no “7” in the resubmission box on the HCFA. Would we remove the lines per the corrected claim?
Answer: No. We would not consider the lines retracted without the corrected claim indicator of “7”, but would make any other corrections that were submitted on the corrected claim.
A call is received from a member regarding a claim that denied for an other insurance update. You update the other insurance tab per the member’s response and adjust the claim. What is the next step?
Answer: Review the account for any other claims denied for other insurance for all members on the plan and adjust any that are outstanding and within the appeal timeframe. (if unsure if the OI response was received with appeal timeframe, use the appropriate appeal calculator within the Appeals/Inquiries PNP)
A member called in to see if their plan would cover developmental delays. What tab would you access in the HPDB to find this information?
Answer: Covered and Excluded Services (D-G) tab.
What P&P is used to identify ineligible codes and what they mean?
Answer: Ineligible Codes P&P
Answer: Claim Compare Tool
When a corrected claim is received and the original claim applied to the deductible, which claim would be adjusted to deny as duplicate?
Answer: Original claim
When the original claim applied to the deductible and no payment was made, the original claim would be denied as a duplicate and the corrected claim would be processed.
What MUST be done before pulling any claim back for adjustment?
Answer: The claim must be reviewed in depth to ensure an adjustment is truly needed.
What tab in the HPDB lists services that may have specific processing instructions or coverage information?
Answer: Special Covered Services/Covid 19
We received a call from a provider regarding a claim that is denied with ineligible code "171". They let us know that they sent in the records that were requested for this claim two weeks ago and would like an update. After a review, you locate the records in OnBase. If no review is found, what department would you forward the records to for a "171" denial?
Answer: Claim Consult
When receiving a call from a TRH member regarding a claim that has denied for pre-existing and the member states they provided their information to Farm Bureau when they purchased the plan, where and how would we check for those documents?
Answer: Where: OnBase How: Searching by member ID, but removing the first three digits.
(Example: If the member's ID is 217800650732, you would enter 800650732 in the member ID box to search)