Rework Reviews
Follow this process for corrected billing claims.
What is the 674p Corrected Billing PI.
When the Fed ID, provider name or NPI, and five-digit ZIP code matches the hard copy of the claim.
What is a three-point match?
The claim is adjusted by decreasing the full payable amount of the entire claim.
What is a Total Down Adjustment?
A claim that is modified from its original submission. Changes could occur in procedure codes, modifiers, place of service, diagnosis codes, or billed amounts
What is a Corrected Claim?
A meeting set up with an external SME for 1 on 1 assistance with claims processing or adjustments.
What is a MYSME session?
Follow this process to determine if the claim was billed within the appropriate timely filing limits for the provider submitting the claim using the UnitedHealthcare default limits, or timely filing exceptions based on the contractual agreements with providers.
What is the 031HP Timely Filing PI?
The charges will note that the submitter is the state agency or its vendor. Instead of reimbursing the actual physician or hospital that performed the service, UnitedHealthcare is required to pay the state Medicaid agency or its vendor, directly.
What is a Medicaid Reclamation Claim?
What is a Total Line Down Adjustment?
Payment to a provider indicated by a solely numeric check number.
What is a paper check?
A COSMOS screen used to look up pay and denial codes.
What is the TB208 screen?
Follow this process to investigate claims with the same service occurring on the same day to determine if they are duplicate claims.
What is the 075P Same Day Same Service PI?
COSMOS screen in which we find the billing zip code.
What is the GI205 screen?
There are not enough payable dollars available to cover an adjustment.
What is Negative Payee status?
A 13-digit number assigned to the claim by the RMO. The fourth through the eighth digits are the Julian date, which is the date the claim was received.
What is a UFE tagline?
A fixed rate paid to a provider per member, per month, for services rendered.
What is Capitation?
Follow this process to assess CMS MIPS (Merit Based Incentive program). The requirements to apply an additional % of payment to the providers bill/claim as a whole. This will occur on non-par physician claims for certain provider billing NPIs. This will occur on a two-step process
What is the 2278 MIPS Procedure Code Add PI?
Record to choose when provider name is same as PCP.
What is a generalist record?
This field is used to tie the re-entered claim to the claim you are adjusting. This causes the claims to go out on the same checkwrite.
What is the Corrected Claim Required field?
The fixed amount you pay each time you receive certain medical services.
What is a copayment?
Reopening – Clerical
Used only for Rework for Non-contracted, Non-supplemental, Medicare claim adjustments due to clerical errors to include human and mechanical errors such as data entry, mathematical, and computational mistakes, inaccurate coding, and computer errors.
What is Cause Code 51?
This edit applies when two claims or detail lines meet the following criteria:
Same date of service
Same procedure code
Same member number
What is the 22 review?
COSMOS screen used to identify panels of existing provider records.
What is the GI201 screen?
What are the TB470/TB471 screens?
Type of claim indicated by entering a "Y" in the Pay Subscriber" field.
What is a DMR (Direct Member Reimbursement)?
A statement provided by the health benefits carrier to the member or provider that explains the benefits provided, the allowable reimbursement amounts, deductibles, coinsurance, or other adjustments taken, and the net amount paid
What is an Explanation of Benefits?