Terms
This is the amount someone will pay over the year before insurance will kick in to pay the full bill for covered healthcare services
OOP
There are this many steps in the billing process.
8
These people run Medicare
Centers for Medicare and Medicaid services
This resource has step by step walkthroughs that are not available in EPolicies
CRT
You would do this if you find that your referring physician on the claim is PAR for trigger CRM59.
Override the medical necessity denial and allow payment of claim
This is an amount owed for covered healthcare services before insurance will help pay.
Deductible
This is the name of the step where we come in.
Monitoring Adjudication
These people can purchase plans offered by Medicare Advantage Plus
Individuals and Employers
You would use system if the information is more up to date than Epolicies.
Systems Communication
This is the amount you would pay if ou are injured during a local game of basketball, you were treated at the ER, and the allowed amount for the service was $4,500.00. You have met your maximum out-of-pocket due to a previous sports injury.
0
A percentage of the bill due at the time of services.
Coinsurance
HRP assigns this to a claim when it drops from Auto Adjudication.
a Trigger
This plan offers both in-network and OON benefits
PPO
This card is used to search for an Authorization.
Utilization
You would do this if you find that the provider on your claim is a specialist for trigger CRMMROL
Apply specialist cost share
This person focuses on a specific medical field
specialist
This process is when HRP processes a claim without manual intervention.
Auto Adjudication
This plan requires the member to select a PCP and obtain referrals.
HMO
This icon is used to add a comment to the audit log outside of a claim.
Pushpin
You would do this if you find that the provider on your claim is not on the CMS certified provider list, and the member is not dual eligible for trigger CRMOTP
Apply ADY$
These plans require participating providers to obtain precertification for certain services.
HMO and PPO
When the system fails to complete a claim, it falls to this basket.
Claims Review and Repair
These three benefits are included in Optional Supplemental Benefits.
Dental, Vision, and Hearing Aids
This is the time frame you have to view any new System Communications.
Immediately.
You would do this if you find that the date of service on your claim is outside of the date range for the member’s hospice coverage for BRHSPCE.
Override the ADMA and ADFA message codes and follow normal processing guidelines.