Training Wave 19

Claims

100

Using Claim 51678305/01 What was the Payment on it?

What is Full PT Responsibility $665 DED

200

Using Claim 48944463/03 what was the Patient Responsibility?

$0 per QL

$298928.44 per EOB as Inelligbile becomes Patient Responsibility

300

Using Claim 52109374/01 What is the Status of this claim?

Line 1 denied as Duplicate Charge

Line 2 with the rest denied as +q DIAGNOSIS DOES NOT WARRANT PROCEDURE. 

Line 3 Denied as Duplicate Charge

Lines 4,5,6 were $0 on Submitted Charges

400

Using Claim 52109374/01 What would the Claim Submitter need to do to get this claim reprocessed?

Claim submitter may submit a Corrected claim.

500

Using Claim 53213807/02 what is the General Claim Status?

REC 12/4/24

Proc 12/10/24

Finalized 12/11/24

TC $225

Allowed Amount $225

Amount Paid to PV $157.50

PT Responsibility $67.50 Coinsurance

Benefits

100

Using Group Cammebys Management Plan CB Quote Chiropractic Benefits.

What is INN 90% After a $40 Co-Pay. Calendar Year Maximum 25 visits. ; Chiropractic Services: OV, manipulations and X-rays are covered under 1 copay per visit and the co-insurance. or OON 60% Deductible Applies. Calendar Year Maximum 25 visits. 

200

Using Group Cammebys Management Quote Infertility Services

Diagnostic Testing 90%. Lifetime Maximum $5,000. ; Artificial Insemination is not covered.

Treatment 60% Deductible Applies. Lifetime Maximum $5,000. ; Artificial Insemination is not covered.

300

Using Zufall Health Center Plan C8 Quote Bariatric Surgery 

What is unable to quote Plan Exclusion

400

Using Zufall Health Center Plan C5 Quote ABA Therapy

$30 copay/100%; Limited to 30 visits per Cal Yr.

500

Using Zoeller Company Plan A4 Quote Bariatric Surgery 

Covered for the treatment of morbid obesity after meeting the following criteria shown in Plan Doc Pgs 51-52

Coding

100

What does the Benefit Suffix P mean?

PPO Network

200

What is the Code you would use to search Physical Therapy Accumulations?

PT

300

What is POS 11?

Physicians Office Visit

400

What code would you use to search Durable Medical Equipment Accums?

DME

500

For Dental Fluoride what code would you search in Accums?

What is DPRF 

PreCert

100

For Zoeller Group Plan A3 who is the Utilization Review 

American Health Holdings

200

For Zoeller Group Plan A3 is PreCert required for Outpatient Surgical Procedures?

What is Yes per Benefit Pointe 

300

For Cammebys Management Group Plan CB would PreCert be required for E0640?

What is Yes E0640 is DME  and found on both BP & Cigna PreCert List

400

Using Davidson Oil Company Group Plan A1 would 70555 require PreCert

Yes per BP & HC PreCert List

500

For Cammebys Management Group Plan CB would PreCert be required for 0586T?

What is Yes found on both BP & Cigna PreCert list as Transplant

Confluence

100

What Page would you use to find a Suffix for Accumulations?

Benefit Suffix 

200

What page would you use to help Member with their ID Cards?

What is ID Cards

300

What page can help you determine what a CPT, HCPCS, DX code may fall under?

Codes - CPT, HCPCS, ID-10 (DX)

400

What Page would you use to help Quote Benefits 

Benefit Quote

500

Using Provider Relations W9 page, What can PV relations do?

• Provider Relations will update the TIN or Address

• They will email you with an update that the TIN or Address has been updated

• You will then be able to proceed accordingly:

  1. Route your call to the processor to request the overpayment from the incorrect address and reprocess it to the correct address

  2. If necessary, send a Check Tracer request (if the criteria is met)