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CLAIMS REVIEW
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What would the Resolution Action be for a member calling in about a denial letter?
Appeal Rights Provided
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How long does a provider have to file a corrected claim?
12 Months from Date of Service
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What would be in documentation for member calling in to check claim status?
DOS, ALLOWED AMOUNT, PAY AMOUNT, PAID DATE, MBR LIABILITY, AND CLAIM #
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If a provider called to have a check reissued for a claim they didn't receive, what must be documented?
The providers financial address
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How long do members have for timely filing?
12 months from the Date of Service
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What is the timely filing for Medicare Advantage Par Providers?
180 Days (6 months) from Date of Service
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When is Denial Code D8 used?
When prior approval not granted because the criteria was not met and the service is being billed without approval.
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If a check was not sent to a correct affiliation, what are the steps to S2W?
Submit to Workflow > MAPD/PDP > Claim > Claim Ops
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If a claim is denied with reason D8, how long does the member have to submit a Post Service Appeal?
60 days from the denial date
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What is the Denial Reason for code D8?
DENY:PAR PROV DO NOT BILL MBR-SVC NOT PRIOR APPROVED & NOT URG/EMERGENT
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Where would you find the Procedure code that was denied on a D8 Denial?
Authorization
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What type of appeal rights do members have with D8 Denial?
Post Service Provider Appeal
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What is the timeframe to process or reprocess a claim?
45 Days
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If a member wants to request a claim form to file claim, what are the steps for s2w?
Submit to Workflow > MAPD/PDP > Claims > Member- Filed Claim
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What is the timely filing for Part D claims filed by Provider?
3 Years from Fill Date
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What two pieces of information should always be in documentation regarding a claim?
Claim # & DOS
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