Quiz on Requesting Adjustments (CHCA/TAT)
Requesting Adjustments Quiz
Test your knowledge on how to properly handle requests for adjustments in claims, particularly related to CHCA and TAT processes. This quiz covers various scenarios that will help you understand the procedures and responses needed.
Key topics include:
- Understanding CHCA and TAT requirements
- Handling claims with missing information
- Communication with clients and members
When sending a CHCA handoff which TAT do you need to provide?
Adjustments
CHCA Unavailable
Member is calling about his claim that was declined due to missing a doctor’s referral for a chiropractor. Can we accept the information verbally or in writing?
Verbally
In writing
A client is calling about a claim with a 3A , 3C – Pended status which was received 10 days ago. Upon checking the claim, you found out that it was selected as part of the quality assurance program. What will you do and tell the client?
Send a release pended handoff and advise that the claim will be processed within 5 business days.
Send a CHCA handoff and advise that the claim will be processed within 5 business days.
No action required. Advise that the claim is still being reviewed and it could take up to 15 business days.
A client submitted a claim for SHU02 and was not paid. In your investigation, you noticed that the item was dispensed by a Physiotherapist. What will you do next?
Apologize and advise the reason it was not paid and tell the client that it was processed accordingly.
Advise it was processed incorrectly and send a CHCA hand-off.
A spouse without express consent called in requesting for the unpaid claim be processed under the member’s HSA benefit. What will you do next?
Send a request to reprocess the claim under the member’s HSA by sending Escalation hand-off, using CHCA Unavailable template.
Advise the spouse that the member can resubmit the claim under the HSA himself using mysunlife.ca or the mobile app when available, if not, then the member needs to call us.
A spouse without express consent is calling about a claim that was denied due to missing doctor’s referral. The spouse said that they already submitted the referral. In your investigation, you found the prescription and it is still valid. What will you tell the spouse?
For this type of adjustment, we must speak to the member. Please ask them to contact us for assistance.
We'll reprocess your claim within 3 business days. We'll send you a claim statement when we're done.
I have sent a request to review your claim. This review will take 5 business days. If we need any additional information, we will follow up with you.
A claim was rejected with a reason remark code DAW. In your investigation, you noticed that there are 3 different providers listed on the receipt. What will you do next?
Ask the member to confirm the name of the provider and send Escalation hand-off, using CHCA Unavailable template.
Ask the member to encircle or highlight the name of the provider on the receipt and resend it by mail or through the web/mobile app.
Based on your answer on the previous question, what will you tell the member about the turnaround time?
Once we have your additional documents, we'll process them within 3 business days. We'll send you a claim statement when we're done.
We'll reprocess your claim within 5 business days. We'll send you a claim statement when we're done.
On November 1, 2021, member submitted an e-claim for glasses and the claim was processed on Nov 5, 2021. The plan's POC period is 90 days after the end of the calendar year. Today, the member is calling to have the claim adjusted indicating that he made an error and that the actual purchase amount was $250. What will you tell the member?
Please send us the receipt showing the correct amount. Once we receive it, we'll reprocess the claim within 3 business days.
I’m sorry, but the time limit to reprocess your claim has elapsed. We will not be able to review your claim any longer.
I will send a request to adjust your claim. We'll reprocess your claim within 5 business days.
On June 1, 2021, member submitted an e-claim for a massage he had on the same day, and the claim was processed and paid the next day, June 2, 2021. The plan's POC period is 365 days after the service date. Today, the member is calling to have the claim adjusted indicating that he made an error and that the actual amount was $90. What will you tell the member?
Please send us the receipt showing the correct amount. Once we receive it, we'll reprocess the claim within 3 business days.
I’m sorry, but the time limit to reprocess your claim has elapsed. We will not be able to review your claim any longer.
I will send a request to adjust your claim. We'll reprocess your claim within 5 business days.
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