D-1
What is the request for payment called when a provider sends information to Humana asking to be paid for their services?
Claim
CRM Contact Handling Alerts remind you additional training is required to support what type of claims call?
IPA related
Which CAS screen is used to search for claims not found in CRM?
MDI
True or False. If a claim is from an in-network provider, payment cannot be sent to the member.
True
A group of providers that will always process as participating, even if they are not; if the member uses an in-network hospital.
PARE Providers
When Humana receives a claim, a claim ID is assigned as it is inventoried in CAS. Benefits are then issued based on the billing codes submitted and the member’s medical plan. There are three possible processing outcomes: the charges may be ___, ____, or _____.
Paid, Denied, or Partially Denied
Which code assigned during processing categorizes the reason services were rendered?
Cause codes
Which CRM shortcut link is used to access CAS?
CAS Claim Prefill
Which Mentor document is the starting point for all claim related calls?
Claims Determination Overview
What modifier should be placed at the end of the MHI control line to display Specialist Codes?
SPEC
This describes the fee structure that providers agree to be paid by Medicare for their services. Providers indicate on the claim form when they accept this kind of agreement.
Medicare Assignment
This tool can be referenced for claims involving older plans or as a back-up if DEBUT is not available.
Benefit grid
Charges from a Primary Care Physician (PCP), or specialist who receives a capitation statement rather than a check
Encounter
Which application is used to view hard copy images of claims, medical records, or appeal requests?
HIVS
The PRI Screen in CAS is used for what type of authorizations?
Inpatient hospital admissions
What is the EMME Code used when sending a medical claim form through the member's mail?
ME2798
A procedure code changed during the claim adjudication process to more accurately match the ICD-10 diagnosis is an example of ___________.
Code editing logic
Which CAS screen contains member benefit accumulation information?
MAI
What happens if a member is inpatient at the end of a calendar year and into the beginning of the next calendar year? For example, the inpatient stay is 12/29/2024 - 01/10/2025.
The claim payment is based off the admit date.
This waiver authorizes members to be treated by non-participating providers/facilities at the participating reimbursement level when in-network providers are not available within a 50-mile radius, or 30 miles for RPPO members
Network Deficiency Waiver
What are the three types of claim forms, and what is each one used for?
Two Mentor documents we use to interpret and give resolution to a certain EX code. (keywords are okay but double points if you can give the exact titles)
How are Encounter claims identified in CRM and CAS?
By the Payee code in CRM or P field in CAS
Which supporting department handles reissuing member payments for checks with a void, outstanding, stop payment, or escheat status?
Provider Payment Integration (PPI)
Which tool verifies a provider's network status the fastest via automation?
CAS POST PRV VERIF process in DIG