Paper Claims/COB
This is the network you choose when entering a paper claim.
None
A processor should do this before making changes to the LOL claim for processing.
Calculate
When would a processor deny a Medicare claim with Deny Benefits - Medicare Secondary?
When FMCP is prrimary.
Does genetic testing, such as BRCA testing, require pre-cert when the procedure code is not on the pre-cert list?
Yes
Although not a medical doctor, this doctor will be there for you when you want to know about paleontology.
Doctor Ross Geller
This should be the Payer Sequence when paying COB claims.
Secondary
When a processor must make changes to the LOL service lines on a claim, check this first.
Accumulators
This OI rule is used when processing Medicare.
Medicare Allowed
Do inpatient claims with a 450 revenue code require authorization?
Yes
This O.G. doctor you will want with you if you you boldly go where no man has before.
Doctor Leonard 'Bones' McCoy
Two documents are required when a member submits a paper claim; the claim and this.
An itemized bill
This is the TOS that should be used when making a LOL claim take an ER co-pay.
ERI-Emergency Room Institution
Why would a processor check 'Patient Maintenance' when processing a Medicare claim?
To verify Medicare is primary
When an authorization has been denied, what other denial is used besides Not Medically Necessary?
Experimental/Investigational
A child prodigy, this doctor graduated from high school at age 9.
Doctor Doogie Howser
A CO is listed on the primary payer's EOB, The OI rule for this claim should be this.
Other Carrier's Allowed Amount
Other than ER co-pay being taken correctly, when else can a processor let the LOL claim go through without any intervention?
When the patient liability is $0.00
The only TOS limit we adhere to when processing Medicare claims is this.
SNF (Skilled Nursing Facility)
When to J-codes/Q-codes on the pre-cert list not require an authorization?
Under $250.00
He likes a nice bottle of chianti and fava beans.
Doctor Hannibal Lector
These two pieces of information are added to calculate the other insurance allowed amount.
Patient Responsibility and OI Paid
Other than being in the queue and seeing red on the claim screen, what information indicates it is a LOL claim?
Negative Discount/Negative Contractual Amount
Always check this before processing a Medicare claim to verify this. (2 part answer)
Claims Alerts - Correct ID
Is there ever a time an inpatient claim would not require an authorization?
Yes, well newborn and/or spouse maternity
This doctor frequently visits a place where everyone knows your name.
Doctor Frasier Crane