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Medical Claims Service Specialist
Published
Hybrid Apprenticeship
Industries
O*Net Code
13-1031.00
Rapids Code
Req. Hours
0
State
MT
Created
Jul 16, 2021
Updated
Jul 16, 2021
Competency-Based Skills
25 skill sets | 152 total skills
Claims Examiner Competencies: Basic Claims and benefits
Reading Explanation of Benefits (EOB) – Member and Provider
Summary Plan Descriptions (SPD): Schedule, Benefits, Exclusions
Basic Claims Processing: Preferred Provider Organization (PPO) & Usual, Customary and Reasonable (UCR)/ Maximum Eligible Expense (MEE)
Looking at claims in Luminx
Common Procedures
Claims Examiner Competencies: Luminx
How to view patient information
Each F7 menu option
Sending and Receiving Follow Ups
Viewing Claims
Viewing Correspondence
Reviewing blood hound edits
Voids
Claims Examiner Competencies: Software and websites
Viewing documents on File Net
Claims Examiner Competencies: Dental and Vision
Learning dental and vision terminology
Benefits
Claim forms/receipts
Luminx accumulators
Coding, service codes, etc.
Claims Examiner Competencies: PPO & UCR/MEE
PPO Networks
Online provider search
PPO Disputes
Provider Services
PPO Rx
Cigna’s ancillary networks
Cigna’s phone tree
Cigna Repricing groups
Reviewing UCR/MEE amounts on claims
Looking up UCR/MEE amounts in Luminx
Determining when each will apply
Claims Examiner Competencies: Patient Protection and Affordable Care Act (PPACA)
Grandfathered vs Non-Grandfathered
Preventive Care
Pre- existing
Claims Examiner Competencies: Pharmacy
Pharmacy Benefits Manager (PBM)
What Customer Service can assist with
Pharmacy Benefits
Vacation Over rides
Diabetic Supplies
Most Commonly Asked Questions
Claims Examiner Competencies: Coordination of Benefits (COB)
Order of benefit determinations
COB records
Annual COB
Auto COB
COB vs Third Party Liability (TPL) and subrogation
Accident Claim Form (ACF)
COB with medical payment from homeowners and auto insurances
COB with Medicare parts A, B and D
Timely Filing for Medicare
Reviewing Medicare cross over claims
Reviewing Medicare EOBs
Claims Examiner Competencies: Major Services
Durable Medical Equipment (DME)
Surgeries
Home Health
Infusions
Fertility
Obesity
Dialysis
Testosterone Therapy
Mental Nervous
Independent Medical Review (IMR)
Clinical Trails
Cancer
Transplants & Center of Excellences
Air Ambulance
When they are submitted
What to include in IMR packets
Claims Examiner Competencies: Appeals
Classifying/ Prioritizing and Handling
Pre-service VS Post-service
What can be appealed
Preparing Appeal Packets
Claims Examiner Competencies: Surgery Claims
Surgery codes and modifiers
Special Network Considerations
Claims Examiner Competencies: Reports
Types of reports received: Stop Loss, Suspended Claims, etc.
How to work them
Claims Examiner Competencies: Stop Loss Renewals
Prioritizing Cases
Collecting Claims and Documentations
Processing Claims
Claims Examiner Competencies: Intermediate Claims
Preparing Claims
Writing Message to intermediate examiner
Customer Service Representative Competencies: Basic Claims and benefits
Reading Explanation of Benefits (EOB) – Member and Provider
Summary Plan Descriptions (SPD): Schedule, Benefits, Exclusions
Basic Claims Processing: Preferred Provider Organization (PPO) & Usual, Customary and Reasonable (UCR)/ Maximum Eligible Expense (MEE)
Looking at claims in Luminx
Common Procedures
Disclaimer
Customer Service Representative Competencies: Luminx
How to view patient information
Each F7 menu option
Sending and Receiving Follow Ups
Viewing Claims
Viewing Correspondence
Reviewing blood hound edits
Voids
Customer Service Representative Competencies: Software and websites
Assisting members with Luminx Information Network (LIN) and Single Sign On (SSO)
Viewing ID cards on Clarity
View ID cards and EOBs on RedCard
Assisting members with Health Care Blue Book
Viewing documents on File Net
Customer Service Representative Competencies: Dental and Vision
Learning dental and vision terminology
Benefits
Claim forms/receipts
Luminx accumulators
Coding, service codes, etc.
Customer Service Representative Competencies: PPO & UCR/MEE
PPO Networks
Online provider search
PPO Disputes
Provider Services
PPO Rx
Cigna’s ancillary networks
Cigna’s phone tree
Cigna Repricing groups
Reviewing UCR/MEE amounts on claims
Looking up UCR/MEE amounts in Luminx
Determining when each will apply
Customer Service Representative Competencies: Patient Protection and Affordable Care Act (PPACA)
Grandfathered vs Non-Grandfathered
Preventive Care
Pre- existing
Customer Service Representative Competencies: Pharmacy
Pharmacy Benefits Manager (PBM)
What Customer Service can assist with
Pharmacy Benefits
Vacation Over rides
Diabetic Supplies
Most Commonly Asked Questions
Customer Service Representative Competencies: Coordination of Benefits (COB)
Order of benefit determinations
COB records
Annual COB
Auto COB
COB vs Third Party Liability (TPL) and subrogation
Accident Claim Form (ACF)
COB with medical payment from homeowners and auto insurances
COB with Medicare parts A, B and D
Timely Filing for Medicare
Reviewing Medicare cross over claims
Reviewing Medicare EOBs
Customer Service Representative Competencies: Major Services
Durable Medical Equipment (DME)
Surgeries
Home Health
Infusions
Fertility
Obesity
Dialysis
Testosterone Therapy
Mental Nervous
Independent Medical Review (IMR)
Clinical Trails
Cancer
Transplants & Center of Excellences
Air Ambulance
Customer Service Representative Competencies: Other Departments
Stop Loss
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Enrollment
Flex, HSA (Health Savings Accounts, and HRA (Health Reimbursement Accounts)
Customer Service Representative Competencies: IMRs
When they are submitted
What to include in IMR packets
