Chapter 7 Claims

Question 1

Identify five main stages in the claims process

Answer 1

Visit GP or specialist
Specialist determines treatment nd carries it out
Bills submitted to healthcare insurer
Healthcare insurer processes claims against benefits entitlement
Insurer sends remittance to medical provider and notifies customer

Question 2

Identify six advantages of electronic billing

Answer 2

Faster
Hospital can liaise with insurer
Data checks reduce mistakes
Paperwork eliminated
In the event of shortfall customer told early
Reduces claims cost and improves efficiency

Question 3

Under Act can customers claim damages for late payment of claims

Answer 3

Enterprise Act 2016

Question 4

Two reasons insurers should notify customer than medical provider has been paid

Answer 4

Courtesy

So customer can pay any excess

Question 5

What are procedure codes used?

Answer 5

To assist in the rapid assessment of claims

Question 6

What does OPCS stand for?

Answer 6

Office of Population, Censuses and Surveys

Question 7

What does CCSG stand for?

Answer 7

Clinical Coding and Schedule Development

Question 8

Identify two types of surgical procedure codes

Answer 8

OPCS

CCSG

Question 9

Which organisation classifies diseases and impairments

Answer 9

WHO World Health Organisation

Question 10

Identify seven initatives PMI insurers are using to control costs

Answer 10

Pricing agreements with hospitals 
Day case surgery
Clinical guidelines
Hospital networks
Consultant networks
Case management and managed care
Open referral

Question 11

Identify four features of Health cash plan claims

Answer 11

Small value/high frequency
Treatment is carried out by known provider
Great checking of high value claims
Benefits written by third party insurer will mean third party insurer will handle claims

Question 12

Who usually pays the dentist under a Dental health cash plan

Answer 12

Customer who claims with copy invoice

Question 13

Who is the HICFG

Answer 13

Health Insurance Counter Fraud Group of insurers

Question 14

Three ways HICFG members work together to combat PMI fraud

Answer 14

Exchange information
Undergo training
Discuss common issues

Question 15

Identify 4 reasons why an insurer may refuse to authorise treatment

Answer 15

Onset of condition started before policy started
Claims relates wholly or partly to time before policy
Treatment not likely to be effective
The Treatment has failed to secure improvement previously

Question 16

What do we mean by pre-authorisation?

Answer 16

Where insurer is consulted prior to member receiving treatment

Question 17

What do we mean by case management

Answer 17

Where medically trained staff working for insurer manage claims against the most usual procedure for that condition

Question 18

Identify 4 advantages of pricing agreements

Answer 18

Customer not concerned with paying hospital
Customer knows costs are within hospital band
Hospitals guaranteed payment without delay
Insures can influence hospital pricing decisions

Question 19

Identify 2 disadvantages of pricing agreements

Answer 19

Claimant detached from cost control process

Potential for misunderstandings if hospitals part paid by insurer part paid by patient

Question 20

What is the definition of a recognised specialist

Answer 20

A person having knowledge and expertise relevant to the injury or illness to which the treatment relates

Question 21

Identify 10 eligibility checks

Answer 21

Is patient covered
Are symptoms covered
Id condition acute or chronic
Are premiums paid
Have annual limits been already claimed
Was treatment provided in accordance with policy terms
Does an exclusion apply
Is the condition pre-existing
Is there non disclosure
Was treatment received in recognised establishment

Question 22

Identify 7 purposes of a claim form

Answer 22

Identify customer/claimant
Indicate history and nature of the condition being treated
Identify dates of treatment
Identify name of medical specialist and hospital
include patients declaration and consent form
obtain declaration that patient has had treatment - if relevant

Question 23

What do we mean by managed care

Answer 23

Ensures all procedures undertaken are medically necessary and less expensive treatments are considered

Question 24

What is an open referral

Answer 24

Where GP give open referral to any specialist