Claims

What is it called when there is an adjudication of claims when two or more medical plans cover the services in question?

Member Tim Brady received a bill for $500 from a participating provider, and after reviewing the claim, you see that the total bill is $1000. Further research shows that CarePlus has paid $400 and the member’s responsibility is showing as$100 copay. Which STC would you use to document this call?

Member Tim Brady received a bill for $500 from a participating specialist.  After reviewing the claim, you see that the total bill is $1000. Further research shows that CarePlus has paid $400 and the member’s responsibility is showing as$100 copay. Would you advise the member he is responsible for the $500 charge? 

Member calls to inquire about his latest EOB. You open the claim in question and see the status as P. You view the CHK screen and see that we paid $0.00. The claim has an adjustment code listing D8. Which STC code would you use to document the call?

Member calls to inquire about his latest EOB. You open the claim in question and see the status as P.  You view the CHK screen and see that we paid $0.00. The claim has an adjustment code listing D8. How would you educate the member?

Member calls indicating he received a notice of denial for blood work he completed at Quest Diagnostics. During your research, you were able to locate the claim in question and confirmed the claim has adjustment code D64 which indicates "Denied Lab procedures must be performed by the contracted laboratory, Labcorp." You advise the member of why the claim was denied and he states the PCP is the one who ordered him to go to Quest. You confirm in the CADD screen that the referring provider is in fact the member's assigned PCP. What STC code do you use to document the call?

Member calls indicating he received a notice of denial for blood work he completed at Quest Diagnostics. During your research, you were able to locate the claim in question and confirmed the claim has adjustment code D64 which indicates "Denied Lab procedures must be performed by the contracted laboratory, Labcorp." You advise the member of why the claim was denied and he states the PCP is the one who ordered him to go to Quest. You confirm in the CADD screen that the referring provider is in fact the member's assigned PCP.  How would you assist this member?

When documenting a member inquiry regarding an EOB, you should always advise of:

Match the CSIM command to its corelating screen:

A member calls the plan regarding an emergency room claim from last month. The member indicates they were in a car accident and suffered a concussion that required treatment. Upon review of the claim, you confirmed the claim is in the process of being reviewed by the driver’s insurance company. What STC code would you use to document this call?

Member contacts the plan advising that they paid $400 out of pocket for new glasses at Costco. The member indicates that she decided to pay out of pocket for new glasses because it was easier for her to go to Costco then to see a network provider. The member states she feels that CarePlus should pay her back the money she spent on her glasses since she has the benefit in her plan. The member asks how she can go about asking for her money back.  What STC code would you use to document this call?

After educating a member on the reimbursement submission methods, the member states that she is unable to send a written request to us due to her severe arthritis not allowing her to write. The member states she doesn’t think with the pain she can even complete a simple form to initiate her request. How can we assist the member?

A CAR can be submitted under all listed circumstances, except: