ClaimsOnline version To check advocates understanding on claims topic. by Natalia Suarez 1 What is a claim? a It is a bill that members and providers receive from UHC to be paid. b A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered. c A request to send a check to the members in order to cover their medical services including prescription. d A bill that is send to the member in order to let them know about the copayment that they have to pay for medical services and prescription coverage. 2 What is the tool that advocates can use to send an explanation of benefits to the member? a VIEW b KNOWLEDGE CENTRAL c DOC360 d ICUE 3 What is a delegated claim? a UnitedHealthCare process member's claims, and send an EOB to members and providers. b Claims are processed by Medicare and Medicaid. UnitedHealthCare does not cover member's services c It is a process where PMG, Medicare, and Medicaid cover part C and pert D in behalf of the member. d It is a formal process where UnitedHealthcare gives a contracting Medical Group/Provider the responsibility and authority to perform specific functions like claims processing 4 If a member is calling from WV to check a claim for dental services, what is the process that advocates have to follow? a Advocates open the account - open review claim history - look for the date of service - advise the member about their copayment. b Advocate open the account - open review claim history - look for the date of service - open review medical claims to confirm member's copay - advise the member about their responsibility (Copay) c Advocate open the account - ask for the date of service - ask to the member about other inquiry - confirm that member has dental benefits - warm transfer to Dental department. d Advocate do not open the account - advise the member that call to dental department - disconnect the call. 5 How long does it take to process a claim if the provider is PAR? a 90 business days b 30 business days c 90 calendar days d 30 - 60 calendar days 6 If a claim is PENDING, what does it mean? a Claim is pending because provider needs to send additional information b Claim was processed but the provider did not receive the payment. c Claim, it is being reviewed to resolve some discrepancy d Claim was already paid but the member needs to pay the copayment Feedback 5 Advocates take into account that providers have a time limit to submit the claim to UHC. 6 Check claim status on Review Claim History
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