Duplicate Claims
Where do you go in Javelina to view modifiers?
Original claim
What F key do you use to view the allowed amount?
F10
What is the name of the template to search for the Patient Reason DX on the Targeted ER DX Codes list?
JV AM CLAIMS EMAIL TEMPLATE
What application does LEA use to verify network pricing?
Javelina
IF
The claim line is not pended for precertification, and no pre-certification is linked to the claim in Javelina then ________.
No precertification is required, and the claim can be paid.
Does the DOS and provider have to match for a claim to be considered a duplicate?
Yes
IF
SPP Allowed Show T1 in audit trail
or $0 pricing THEN ______
Use Anthem allowed to finalize claim and continue with standard claim processing.
Action complete.
What box on your claim from would you find your patient reason dx?
70
What entity is wgs837?
Anthem
What does RB1 stand for?
General Room and Board
Do the modifiers have to match to be a true duplicate?
Yes, the modifiers must match exactly on the original and possible duplicate claim for the claim to be a true duplicate.
IF
Write off amount is less than
Anthem Allowed amount on any one
line, THEN ______
Apply a full write off amount to the one line.
What is the password used to access any BPD?
LEA123
On the audit trail what reject code will let you know a claim is out-of-network?
T1 Reject Code
What do statement dates represent?
Statement dates represent the span of time the patient was in the hospital.
Which date (incurred or received) determines the correct action needed to process a duplicate claim?
received
What is the reason code when modifying a service line for a SPP pricing adjustment?
SPP
IF-
Plan does not have non-emergency benefits and, in the JAVELINA AM CLAIM EMAIL TEMPLATE, the ER Denials field indicates: NO ER HOLDS
THEN______
Do not deny for UB ER review. Continue with the standard claim process.
Action complete
Does this entity, Wgsppl837, mean SPP?
No, this is Anthem network (PPL)
What does MC5 stand for?
Newborn Care
What does the modifier 77 represent?
The 77 modifier represents a repeat procedure by another physician
Is this a proper note to leave on your SPP claim?
SPP Pricing 223-00000XXXXX-00 ALLOWED 56.33 ANTHEM LESSER
YES
What term would you search for ER benefits on a BPD?
Emergency Care Benefit
What is the CPG denial code if network does not match in BPD and audit trail?
ENT
If I can't find a matching authorization for PT, ST or OT but an Umbrella code authorization exists, can I use that authorization?
Yes