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Methodology Questionnaire

A professional office environment with individuals discussing medical claims and charts, focused on a computer screen displaying methodology related to healthcare provider inquiries.

Methodology Provider Quiz

Test your knowledge on methodology protocols when dealing with provider inquiries. This quiz is designed for professionals who want to ensure they are following best practices in claim management.

Key points to consider:

Understand the correct procedures for handling provider inquiries.
Learn about the methodologies to explain to providers.
Evaluate your understanding of claims processing with major insurance providers.

10 Questions2 MinutesCreated by AnalyzingData247

1.) When do I give methodology to the provider who called in?

A. All client for providers calling in.

B. To providers on claims for UHC EPDP, Oxford EPDP, Aetna and Cigna SOD.

C. All the above.

2.) After giving methodology to the inbound provider calls for an Aetna claim, if the provider will not accept the DIS Provider Accept amount, I close the provider inquiry as:

A. Inquiry Resolved

B. Maximum Allowed Paid

C. I do not close the provider inquiry after giving the methodology for an Aetna claim.

3.) After giving methodology to the inbound provider call for an Oxford EPDP or UHC EPDP claim, if the provider will not accept the DIS Provider Accept amount, I close the provider inquiry as:

A. Inquiry Resolved

B. Maximum Allowed Paid

C. I auto assign the provider inquiry.

4.) True or False – On a provider inbound phone call, after giving the methodology, if the claim is not for Aetna, Oxford EPDP, UHC EPDP, Cigna stand on, I auto assign the Provider Inquiry letting them know you will forward the inquiry for an additional review for an associate to contact them with next available steps?

True

False

5.) True or False – If the member is on the phone, and I am opening a member inquiry after verifying they received a balance bill, I obtain the member phone # and member email address. I only have the member submit the copy of the balance bill to Verify Docs if the claim is for UMR, UHC, UHC EPDP, Oxford, and Oxford EPDP.

True

False

A.) If you identify it is a balance bill do you:

A. Auto assign the Member Inquiry

B. Close the Member Inquiry as Internal Resolution

C. Manually assign the Member Inquiry to DID.

D. Manually assign the Member Inquiry to D1D.

6.) True or False – if the member is on the phone, and I verify it is a PAD letter, I open a Member Inquiry, document the call and close Internal Resolution.

True

False

7.) When a provider is willing to accept the Data iSight allowed amount, after explain and defending the methodology, I do the following steps:

A. Generate a DIS Provider Accept Letter of Term, selecting provider accept DIS original rate option.

B. Verify provider fax # or email address

C. Add provider contact information if not in Toolbox

D. Make sure your name is listed as the “Negotiator” on the open claim.

E. Check status every 2 business days.

F. Close after 3 attempts.

G. None of the above.

H. All of the above.

8.) True or False - If the provider does not sign the Letter of Term, and there is no response from the provider, you auto assign the provider inquiry issue when the claim is not for Aetna, UHC EPDP, Oxford EPDP, or Cigna stand on.

True

False

9.) Which methodologies do I explain to the provider:

A. Phys RVU

B. HCPC median

C. Ambulance % of Medicare

D. Anesthesia % of Medicare

E. All of the above.

F. C and D only.

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