PRELIMINARY ACTIVITY - CLAIMS PROCESS WORKFLOW

A claim amount should follow which value when comparing SOA and EW rates?

• Always the higher one

• Whichever is in SOA

• The lower of the two

• Fixed EW rate

What must be cross-checked before encoding HB?

• Date Received

• SOA vs. LOA

• SOA vs. Transmittal

• LOA vs. ERP

• What is indicated by the "Date of Loss"?

• • The date the document was scanned

• • The date the claim was denied

• • The date of service availed

• • The date the patient paid the bill

Which code is validated to confirm claim authorization?

• ERP ID

• Claim Number

• Approval Code

• Billing Code

A claim without availment type or diagnosis is considered:

• Invalid

• Pending

• On-hold

• Complete

The Eastwest Rate should be followed even if the SOA rate is lower.

• TRUE

• FALSE

The Approval Code is issued by hotline agents and is required for most claim types.

• TRUE

• FALSE

Claims without any processed amount cannot move to batching.

• TRUE

• FALSE

Claims without any processed amount cannot move to batching. Verification of consultation rates must consider both the doctor's group and utilization year.

• TRUE

• FALSE

You are encoding PF but the doctor is not searchable in ERP. What should you do?

• Skip encoding for now

• Use a random doctor in the system

• Encode the PF under the hospital

• Request Dr. Ken Lascano to add the doctor