Payor and Plan Setup

Question 1

True or False: Any settings at the benefit plan level will always override at the payor level

Answer 1

True (More Specific)

Therefore, it is possible to set up a payor with multiple plans, all of which may behave in different ways

Question 2

Define a rider

Answer 2

Associated with a coverage, through a plan group (employer group), and defines additional optional terms that may apply to some of the members on the coverage

Question 3

Define Financial Class

Answer 3

Item in payor record; grouping together payors for reporting purposes (Medicaid/Medicare etc). It is a required field

Question 4

Which items of a benefit plan is tracked over time?

Answer 4

Plan notes
Benefit Package
Limit variables
Payment variables 
These benefit items are automatically copied into the new contact from the previous contact. However the "Release Field" is automatically set to "NO" regardless of the setting in the previous contract

Question 5

Define product type

Answer 5

A way of grouping plans together for reporting purposes. Not required.

Question 6

What is benefit engine used for?

Answer 6

To adjudicate the patient portion of a procedure, referral, claim, or visit. To determine what is covered, how it is covered, and what to the extent in which is covered.

Question 7

True or False: The benefits engine requires a benefit package which is linked to a specific benefit’s plan, which is then linked to the coverage

Answer 7

True

Question 8

What are some functions of a CDF:

Answer 8

Send certain comp groups to a different form or address
define claim split/sort options
force electronic charges/claims to paper
send claims to the error pool
to map internal/external data on the forms
create custom errors and reason for split runs

Question 9

True or False: CDF contains most payer’s requirements attached to a payor or plan. The most specific settings are located in the CDF may override the same setting at a higher level

Answer 9

True

Question 10

Define Payor Filing Order

Answer 10

Where the payor should be assigned in the list of patient’s current list of payors.
Two areas:
Patient level (default)
Visit level
Can be overridden in PB by the PB visit order

Question 11

True or False: The first place the system looks to determine the filing order is the Payor Filing Order field in the payor master

Answer 11

True

Question 12

What are 3 filing indicators for a payor filing order?

Answer 12

As entered: Is the default setting (based on algorithm)

Always First: Payor that is placed at the top of the filing order

Always Last: Bottom of the patient’s filing order

Question 13

True or False: You cannot exclude a payor or plan from a visit’s filing order (during PB claims processing/printing only) in certain circumstances or on the claim form print options

Answer 13

False: You can exclude a payor or plan from a visit’s filing order

Question 14

Define “File Claim”

Answer 14

Defines when a charge should be sent on a claim
-Always [Y]
-Never [N]
-On Assignment [Y]or [N] (or leave this field blank to print a claim only for procedures covered by the payor)
The ‘CLM’ Box in Charge entry
[Y] [N]
This value can be overridden

Question 15

Define Claim Max Days:

Answer 15

The number of days that is the timely filing limit. How many days after the service date will the payor accept the claim

Question 16

True or False: You can suppress claims based on the number of days in the claim max days

Answer 16

False

Question 17

Name three actions performed in Epic for Crossover Claims

Answer 17

Suppress: Suppress the secondary claim (in which are receiving from the primary)–which must be present in the Payor’s crossover option’s list

Increment the secondary claim invoice number (02)

Follow up record(s) is created

Please note: if you resubmit a secondary claim, a charge is sent out on a claim and is not suppress

Question 18

Define Coverage Specific Patient Names:

Answer 18

a feature in which you can enable a function to the patient’s name from the coverage record instead at the patient’s record.
-Use Coverage Specific Name—YES

Question 19

Define Alternative Payors:

Answer 19

Alternative payor relationships allow the system to track simultaneous responsibility for a visit. Two payors can be primary payors for different services.

Question 20

True or False: The alternative payor will need to be selected in registration

Answer 20

False: Only the coverage payor will be added in registration bc the charges are split automatically

Question 21

True or False: For PB, the system determines when to bill a charge to the alternative payor based on the component or component groups you define as the responsibility of the alternative payor in the benefit plan record

Answer 21

True

Question 22

In which payor master file would you list a crossover payor, a payor who is typically primary or a payor who is typically secondary

Answer 22

List the secondary (crossover) payor information in the primary payer’s record

Question 23

Where is the first place the system looks to determine payor filing order? (Give the master file and specific setting)

Answer 23

EPM

Payor filing Order Settings

Question 24

A benefit plan can be attached to how many payors?

Answer 24

1

Question 25

True or False: If you restrict a payor or plan by a service area, the payor or plan cannot be used in that service area

Answer 25

False, that payor or plan can ONLY be used in that service area

Question 26

True or False: Benefit packages can be attached directly to a payor record

Answer 26

False, they can be attached directly to the benefit plan (who is directly attached to the payer’s record)

Question 27

What is one reason for assigning each payor to a financial class?

Answer 27

Reporting/grouping of payors

Question 28

In order for the Benefits Engine to consider anything to be covered it must be attached and……

Answer 28

Released