Benefits & Eligibility
True or False: We can quote benefits if member is termed and DOS is after term date.
False
If the check is on hold for over 20bd, where do we escalate and what is the TAT?
CSR (CART) - TAT 20bd.
What is the status of the claim in CART if it is in process? & What is the TAT for claim processing?
Client Benefit Determination // SIA 45CD from CBDQ, Non-SIA 30BD from CBDQ.
Claims that are denied show as ____________ in CART
Finalized
True or False: We can provide complete MID to a caller if they give us the 9 digit MID and are only missing the prefix
True
What probing questions should we ask for lab benefits?
Sick & Injury or Preventive, and place of service (office setting, facility or hospital setting)
How can we determine the claim payment has been finalized?
Payment date in CPS and Issue Date in Admin are different
Where can we find the true date in which the claim was fwd to the homeplan? & What is the message it says?
Claim Status History Tab, under "claim approved by client for adjudication" or something along those lines
What two systems should we be checking for all types of claim statuses?
CART, CPS
What is our CURRENT JSY Policy
If JSY is applicable, an email to enrollment team must be sent with all mandatory info.
Please note that if the JSY request involves an inpatient or VOB request, the highlighted fields in the template are required when submitting the request to the Enrollment Team.
Member Information (Mandatory) – All Fields in bold must be filled out in this section
Please copy and paste from source (CPS or Admin Portal)
Member First Name:
Member Last Name:
Date of Birth:
Group Number:
Group Name:
UHC Member ID (if available):
Date of service:
Policy Enrollment Information (Optional – if available)
Policy Start Date:
Policy End Date:
Diagnosis & Procedure Information (Optional – If applicable)
Diagnosis Code:
Diagnosis Description:
Procedure Code(s):
Procedure Description:
Service Setting (inpatient or outpatient):
Service Details:
Medical Record #:
Facility Name:
Facility Phone Number:
Physician Name:
Physician Phone Number:
Call‑Trak #
What probing questions should we be asking for office visit benefits?
PCP or Specialist, and if its due to Sick/Injury or Preventive
If the check is on hold for less than 20bd, what do we quote to the provider?
Please allow 30bd for the payment to be received in your system.
What is the TAT for a claim to be finalized if it is in returned status?
5BD
If a claim is denied for TFL, where can we check how many days passed, and what are the next steps for the provider? Also, what is the SOP for timely filing?
We can check in Repricing Sheet in Webclaims, and the provider if they want to appeal, they must submit acceptable proof of timely filing. // KM1407455
Electronically submitted claims require proof that the claim was accepted:
For paper claim submissions, the only acceptable proof is some type of signature receipt:
What is the correct dropdown in BWAA if you are going over Inpatient Hospital benefits and assist the caller with submitting a PA?
Doc type 1:
Doc type 2:
Doc type 1: Benefit Verification
Doc type 2: IP Hospital
True or False: The TAT for all PA's is the same.
False, we need to check in HPDB - SCS
If a provider is disputing a payment amount, where do we submit the dispute and what is the TAT?
Net Ops - 7bd TAT
If a claim is denied for MR, and MR have not been attached to the CSR but we find MR in Onbase, who do we email to request for them to be attached?
UHA_Admin
If a claim has been reprocessed and denied, what should we be pressing in CPS to ensure the most recent denial shown in CART is accurate?
F11 and compare Released Date in CPS to Finalized Date in CART
What is required to be documented for claims calls. Hint: 5 things
DOS, BA, CCN, Claim Status, All pertinent information discussed during the call
What is another term for 1) Chiropractor, 2) Labs and 3) MRI's/Xray/CT Scans
1) Manipulations // 2) Biology // 3) Radiology
Where can we check to see if the payment is single or a bulk payment?
Admin & Check Hold Tracker Excel link
If a claim is denied requesting MR and additional info from the member, and the MR are past TAT, we have to do 1 thing, and also advise the provider _______. What are they?
Check if its attached in TIF, and escalate to UHA_Admin requesting to attach as PDF, and also advise the provider to have the member contact the HP to verify if they have submitted the info. If member says they did, we can contact homeplan to verify
If a claim has reductions towards ICES, can a provider appeal? If yes, how? If no, what are the next steps?
Submit corrected claim.
Where can we find if a plan runs on calendar yr, deductible info, and oopmax info in HPDB? // What tab do we use to quote preventive office visits? // What tab in HPDB can we use to quote Labs done in Office, how about Labs done in Hospital Setting? // Where can I find birth control in HPDB? // Where can I find if PA is required for HPDB driven plans? (3 places)
Schedule of Benefits Tab // Routine Tab // Office visit tab, Outpatient tab // Contraceptives tab // HPDB SCS Tab, Benefit Tab, PA Tab