Review

In Correspondence and Documents Task in ASPEN, ___________ pane allows us to view IQTs related to the member in focus. These letters could be generated from ASPEN, Solution Central or CCB.

• Correspondence & Documents

• Recent Letters

• Historical Letters

• Legacy Based

According to the JAA Promised Action QRG, Promised Action Requests are __________.

• Promised Action Requests are for escalations, requesting for VRU assistance and sending messages to the group/TPA.

• Promised Action Requests are for guaranteed callbacks and additional requests that we promised our callers.

• Promised Action Requests are not for adjusted claims, appeals, etc, but for items needing actual research from someone on our team.

• Promised Action Requests are for adjusted claims, appeals, etc, including items needing actual research from someone on our team.

Using the ClaimsXten Rules on WGS, the rule description _______________  is the rule that denies a line when the procedure is billed with a co-surgeon modifier (modifier 62) and the procedure does not require a co-surgeon according to the CMS Medicare Physician Fee Schedule.

• Co-surgeon not allowed

• Procedure to procedure without diagnosis

• Administrative Appeals

• Clinical Appeal

Using the ClaimsXten Rules on WGS, the rule description _______________  is the rule that will look for lab services billed for the same date of service by different providers. When a lab is billed by two providers on the same date of service, the first claim will be processed and allowed and the second claim will receive a denial.

• Procedure to procedure without diagnosis

• Deny same day office visit.

• Duplicate services across providers

• Co-surgeon not allowed

Who prices the claim in an ITS Home claim situation?

• The local BCBS in an Anthem state

• The Group

• The local BCBS in a non-Anthem state

• None of the Above

In JAA, what is the responsibility of the TPA/Group in both an ITS/Non-ITS Claims situation

• The group/TPA receives, uploads and prices the claim.

• The group The group/TPA adjudicates the claim then sends it back to Anthem.

• The group/TPA sends the Explanation of Benefits to the member and Explanation of Payment to the provider.

• None of the above

After advising that the allowed amount is based on their contract (INN) and the maximum allowable amount (OON), for other questions related to pricing and the check number in an ITS Claim situation, the provider should contact:

• Anthem UM

• The Group

• The local BCBS in the Anthem state

• The local BCBS in the non-Anthem state