CAS
reflects the amount applied to the individual medical deductible for the period on the MHI screen
What is DED?
_________ Providers can balance bill a member. (Claim Index)
what not to do when a provider is angry and using sporadic offensive language.
primary policy for a member with active coverage with humana but listed as a spouse with another plan.
What is humana?
advice for a provider that would like a copy of their 1099 tax form
What is send an e-mail to Accounts Payable (AP)
What is basic?
next steps for a provider who hasn't received payment after 30 days, claim has an EX code of 01J
what not to do when a provider is disputing the home health pricing/claim payment and you determine data elements were keyed in incorrectly
What is transfer to CRU?
system that you can use to see the LCD (Local Coverage Determination" applied to each line of a claim
What is CAS?
the PI field displays this on the MHI screen when a claim has been adjusted
What is 95?
indicates on electronic version of a physician claim that it was submitted as a corrected claim
a note included in the CRM case comments pertaining to a provider's statements when escalating a call where the provider was rude and used derogatory comments.
primary coverage for Tanner who is a dependent under his mom's insurance (ABC) and under his dad's insurance (XYZ). Mom has legal custody
What is ABC insurance?
also referred to as fee schedule
What is Provider Contracted Rates?
location the final processing of an adjusted claim will appear on the MHI screen
guidance for a denied claim with EX code 13C
What is "a local claim determination (LCD) was used to deny the claim; member is responsible for charges"?
how we send cases to CRU when a provider is calling on two different members and both cases need transferred.
what is two cases sent to CRU- One for each member?
location to verify if a claim is already being reviewed by CRU before you route a new case.
What is "case history"
guidance for a provider calling in to find out if authorization is required for inpatient heart bypass surgery. Provider is part of AllCare IPA grouper # 08055186.
What is contact the delegate for inpatient authorization?
modifier used from the MHI screen to view the SD field for duplicate in the member history
What is D?
next steps when a provider says claim is denied and they already submitted medical records to prove the clam is not a duplicate.
provider is participating with humana but does not submit the claim within timely filing limits, then the provider must _________________
What is write off charges and cannot bill member?
guidance when a provider states they have submitted medical records to availity, yet Humana has no record of receiving them
What is contact availity for assistance?
screen will identify either an "N" or a "Y" if a provider is contracted for split billing
What is CFI?