From the details screen, the ________________ button will allow the specialist to view the payment history of a particular claim or claim line.
A.
Remit Hist.
B.
Edits
C.
Adjudicate
D.
Update
3.
If a claim has more than one page, what could this indicate?
A.
An invoice is attached.
B.
An EOB is attached.
C.
The claim is a paper claim with more than 6 lines.
D.
All answers are correct options.
4.
Clicking the "Reject Claim" button at the top of the claim header screen allows the specialist the option to reject either an entire claim or just an particular line.
A.
True
B.
False
5.
In the State of Illinois, it is unacceptable for members to have a primary insurance along with any of Meridians insurance plans.
A.
True
B.
False
6.
The edit "MUE" can mean either one of two things. What are the two things that this edit is asking the specialist to check?
A.
For an authorization and/or signed consent form.
B.
NCCI bundling and/or if the code is included with any other code.
C.
For duplicate claims and/or maximum visits reached.
D.
The age and/or gender for a code.
7.
The special pricing percentage for DME penny codes in the state of Illinois is _________.
A.
15%
B.
5%
C.
17%
D.
25%
8.
Select the answer with the correct order of steps needed to forward a claim when forwarding to Change Healthcare, Appeals, FWA or Member Hold:
A.
Work any edits on the claim, process the claim, hold the claim, add a note to the claim, forward the claim to the appropriate inbox
B.
Realize the claim needs to be forwarded, put the claim on hold, add a note to the claim, forward the claim to the appropriate inbox
C.
Realize the claim needs to be forwarded, forward the claim to the appropriate inbox, hold the claim, and add a note to the claim
D.
Work any edits on the claim, process the claim, add a note to the claim, put the claim on hold, forward the claim to the appropriate inbox
9.
On a HCFA claim form, the resubmission code for a replacement claim is what number?
10.
A Place of Service (POS) of 11 on a HCFA 1500 claim form means the services were rendered in a home setting.
A.
True
B.
False
11.
SASS claims pay under Medicaid. If an specialist comes across a SASS claim and the line of business is selected as Medicare, the specialist is to change the line of business to Medicaid and process the claim
A.
True
B.
False
12.
In the state of Illinois, the administration code of a drug/ vaccine always pays out individually
A.
True
B.
False
13.
What is the maximum allowed in regards to a child's vision hardware benefits?
A.
Once a year
B.
Once every two years
C.
Twice a year
D.
Unlimited
14.
In order to reverse a paid claim, the specialist would select
A.
Reason: Take Back, Type: Replacement, Reason Code: 125
B.
Reason: Replacement, Type: Take Back, Reason Code: 125
C.
Reason: Take Back, Type: 125, Reason Code: Replacement
D.
Reason: 125, Type: Replacement, Reason Code: Take Back
15.
When the CSECT edit flags on a C-SECT procedure code, how would you proceed?
A.
Pay at the vaginal rate
B.
Override the edit and pay at the C-section rate
C.
Reject the claim
D.
Forward the claim to the OB Box
16.
What does HFS stand for?
A.
Home and Family Status
B.
Healthy Family Services
C.
Healthcare and Family Services
D.
Healthcare and Financial Services
17.
What does CMS stand for?
A.
Central Medical Systems
B.
Centers for Medicare and Medicaid Services
C.
Centers of Medical Status
D.
Control for Main Sources
18.
Which folder in MCS would you look up a code to see what the maximum allowed amount of that code is
A.
Procedure Codes
B.
Fee Screen
C.
NCCI
D.
Modifiers
19.
What does DME stand for?
A.
Detroit Medical Emergency
B.
Dual Member Eligible
C.
Durable Medical Equipment
D.
Dearborn Mechanical Equipment
20.
Anesthesia claims must be billed with a _____ modifier.
21.
What modifier represents physical therapy?
22.
This modifier represents a service is bilateral payable.
23.
When filling in transportation data, always round up the number of mileage in the system
A.
True
B.
False
24.
A provider bills with a DME penny code item. The charge for that item is $700.45 and the invoice included with that claim has a cost amount of $465.40. If this claim was manually priced with the correct percentage for IL what would be the payment amount for that item?
25.
What does the acronym MCS stand for?
A.
Management Care Series
B.
Managed Care System
C.
Managerial Care Specialty
D.
Marketing Coordination System
26.
The service location dictates the payment rate that goes out on a T1015 encounter claim
A.
True
B.
False
27.
If a DME item or claim pays this amount or more an authorization is required regardless if AUPRC flags or if the CBT shows no PA required.
A.
$500
B.
$1500
C.
$1000
D.
$2000
28.
What does LMP stand for?
A.
Last Medical Procedure
B.
Long-term Managed Plan
C.
Last Menstrual Period
D.
Limited Medication Policies
29.
A newborn babies charges may be billed under the mother's member ID.
A.
True
B.
False
30.
A _______ _______ is a claim that has been received with no errors and the system accepts it for reimbursement and therefore has no edits to be worked.
31.
A DME item that is a penny code where the billed amount is under $100 is paid at this percentage.
32.
Choose all of the following that are examples of a claims status that can be seen in MCS
A.
Approved
B.
Adjudicated
C.
Rejected
D.
Received
33.
A vendor add request is assigned from the:
A.
Header Screen
B.
Provider's License Number Screen
C.
The member hold inbox
D.
The specialist's personal hold box
34.
A provider bills a penny code for a DME item and charge amount billed on the claim is $85. This claim can be paid without an invoice.
A.
True
B.
False
35.
EOBNC can be used when the provider did not send the denial reason from the primary insurance or when a multi-line HCFA claim has an EOP attached that does not show a line by line break down
A.
True
B.
False
36.
Which edit stands for "Resubmit with a copy of the Primary Insurnace Voucher"?
A.
EOBNC
B.
OISMC
C.
OTINS
D.
ORINC
37.
Speech therapy requires authorization submitted to whom?
A.
Meridian
B.
EviCore
C.
MCS
D.
Speech Therapy does not require an authorization
38.
Select all that are true about Illinois timely filing rules
A.
Provider has 180 days from the date of service to submit a claim to Meridian
B.
Providers have 120 days from the date of service to submit a claim to Meridian
C.
Providers have 180 days from the original received date to submit a replacement claim or appeal
D.
Providers have 120 days from the original received date to submit a replacement claim or appeal
39.
What are the benefit rules for Physical and Occupational Therapy?
A.
PA required through EviCore
B.
Based off fiscal year
C.
24 visits
D.
Based off calendar year
40.
Which claim type(s) are excluded from TPL rules? Select all that apply:
A.
SASS
B.
Waiver/Homemaker
C.
DME
D.
Physical Therapy
41.
Waiver/homemaker claims are the only exception to when a claim does not need a taxonomy code listed on it.
