Week 4

When working an edit for a member who has medicare primary and is enrolled in standard option, the rendering provider is out of our area but has a legacy number in streamline. If not all lines are paid by medicare and some lines are denied with no member liability, can we process the claim here in NY?

No and all lines need to be denied T597 T474

No and we can allow the lines medicare paid with IB02 and deny the lines not paid by Medicare with T597 T474

Yes pay the claim regardless of Medicare Processing

Yes we don't care what Medicare paid we can pay the provider.

The Ambulatory Surgery Center’s claim denied T852. What should the customer service representative advise the provider if there are no corrections that need to be made after reviewing the image of the claim?

The provider should have received a letter from the SUI unit about the claim.

The Member will need to contact us with additional information.

Missing/Incomplete/Invalid HCPCS. Please refer to your Provider Relations Rep for any additional assistance.

The claim will be Plan Approved.

When a VA Group Proivder is keyed, do you need to verify and change the NPI and Tax ID to match box 33 before finalizing the claim?

True

False

When a Dependent question what their premium would be for TCC through the US finance Center how do you calculate what their premium is?

The premium is paid in full for 36 months by the plan .

gov't Share + Your Share = Total Amount X 2% (total amount and 2% get added together for premium).

The original subscriber is required to pay the premium.

There is no such thing as TCC.