Scenario Based Quiz - Non Covered Charges as Provider is Out of Network

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1. What could be the possible reason for the claim to be denied for denial code - 242? The provider is not contracted with the group
The provider is contracted with the group
The provider is not contracted with the insurance
The provider is contracted with the insurance
Click here to go on OON scenario

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2. Do PPO & POS plans cover out-of-netowrk benefit? Yes
No
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3. Do HMO & EPO plans cover out-of-netowrk benefit? Yes
No
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4. If you receive the status on call as the claim is denied for non-covered charges as per patient plan as provider is out-of-network then what will be your next valid question? Does patient plan cover out of network benefit?
Could you please reprocess the claim since patient plan does cover out of network benefit?
What is the TAT for reprocessing?
None of the above
Click here to go on OON scenario

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5. If you receive the status on call as the claim is denied for non-covered charges as per patient plan as provider is out-of-network and the rep confirms the patient plan as HMO then what will be your next valid questions? A. Could you please reprocess the claim since patient plan does cover out of network benefit?
B. What is the TAT for reprocessing?
C. Both A & B
D. None of the above
Click here to go on OON scenario

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6. If you receive the status on call as the claim is denied for non-covered charges as per patient plan as provider is out-of-network and the rep confirms the patient plan as PPO then what will be your next valid questions? A. Could you please reprocess the claim since patient plan does cover out of network benefit?
B. What is the TAT for reprocessing?
C. Both A & B
D. None of the above
Click here to go on OON scenario

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7. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as POS and agrees to send the claim back for reprocessing then what will be your action? Resubmit the claim to insurance
Set the follow-up for the TAT
Assign the claim to the coding team
Release the claim to the patient
Click here to go on OON scenario

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8. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as HMO then what will be your action? Will submit the claim to secondary insurance if it is not active on DOS
Will release the claim to the patient if the secondary insurance is active on DOS
Will release the claim to the patient if no other secondary insurance is available
None of the above
Click here to go on OON scenario

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9. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as EPO and there is secondary insurance available then what will be your action? Will submit the claim to secondary insurance if it is not active on DOS
Will submit the claim to secondary insurance if it is active on DOS
Release the claim to the patient
None of the above
Click here to go on OON scenario

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10. If the claim is denied for non-covered charges as per the patient plan as the provider is out of network and the rep confirms the patient plan as HMO and there is no secondary insurance available then what will be your action? Resubmit the claim to insurance
Set the follow-up for the TAT
Assign the claim to the coding team
Release the claim to the patient
Click here to go on OON scenario

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