Medical Claims Service Specialist

Allegiance Benefit Plan Management

Montana (SAA)

Documents

Individual state requirements may vary. Please contact your local apprenticeship office to ensure this version is suitable to your state’s requirements.

Work Process Schedule

Work Process Content

On the Job Training

Anonymous

Skills

Customer Service Representative Competencies

Basic Claims and benefits a. Reading Explanation of Benefits (EOB) – Member and Provider b. Summary Plan Descriptions (SPD): Schedule, Benefits, Exclusions c. Basic Claims Processing: Preferred Provider Organization (PPO) & Usual, Customary and Reasonable (UCR)/ Maximum Eligible Expense (MEE) d. Looking at claims in Luminx e. Common Procedures f. Disclaimer
Luminx a. How to view patient information b. Each F7 menu option c. Sending and Receiving Follow Ups d. Viewing Claims e. Viewing Correspondence f. Reviewing blood hound edits g. Voids
Software and websites a. Assisting members with Luminx Information Network (LIN) and Single Sign On (SSO) b. Viewing ID cards on Clarity c. View ID cards and EOBs on RedCard d. Assisting members with Health Care Blue Book e. Viewing documents on File Net
Dental and Vision a. Learning dental and vision terminology b. Benefits c. Claim forms/receipts d. Luminx accumulators e. Coding, service codes, etc.
PPO & UCR/MEE a. PPO Networks b. Online provider search c. PPO Disputes d. Provider Services e. PPO Rx f. Cigna’s ancillary networks g. Cigna’s phone tree h. Cigna Repricing groups i. Reviewing UCR/MEE amounts on claims j. Looking up UCR/MEE amounts in Luminx k. Determining when each will apply
Patient Protection and Affordable Care Act (PPACA) a. Grandfathered vs Non-Grandfathered b. Preventive Care c. Pre- existing
Pharmacy a. Pharmacy Benefits Manager (PBM) b. What Customer Service can assist with c. Pharmacy Benefits d. Vacation Over rides e. Diabetic Supplies f. Most Commonly Asked Questions
Coordination of Benefits (COB) a. Order of benefit determinations b. COB records c. Annual COB d. Auto COB e. COB vs Third Party Liability (TPL) and subrogation f. Accident Claim Form (ACF) g. COB with medical payment from homeowners and auto insurances h. COB with Medicare parts A, B and D i. Timely Filing for Medicare j. Reviewing Medicare cross over claims k. Reviewing Medicare EOBs
Major Services a. Durable Medical Equipment (DME) b. Surgeries c. Home Health d. Infusions e. Fertility f. Obesity g. Dialysis h. Testosterone Therapy i. Mental Nervous j. Independent Medical Review (IMR) k. Clinical Trails l. Cancer m. Transplants & Center of Excellences n. Air Ambulance
Other Departments a. Stop Loss b. Consolidated Omnibus Budget Reconciliation Act (COBRA) c. Enrollment d. Flex, HSA (Health Savings Accounts, and HRA (Health Reimbursement Accounts)
IMRs a. When they are submitted b. What to include in IMR packets
Appeals a. Classifying/ Prioritizing and Handling b. Pre-service VS Post-service c. What can be appealed d. Preparing Appeal Packets

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Medical Claims Service Specialist

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