Scenario Based Quiz - Capitation Agreement / Managed Care Plan

     10 comments
1. What is Capitation?




2. If you receive the status on call as the claim is denied for denial code - 24 and the payer is Medicare or Medicaid then what will be your next valid questions?




3. If the claim is denied for denial code - 24 from Medicare payer and you are able to find the managed care information on the Medicare website but unable to find policy ID for managed care insurance and you do not have a website of managed care insurance then what will be your action?




4. If the claim is denied for denial code - 24 from non Medicare/Medicaid payer and the rep confirms that the patient is not covered under the capitation and agrees to reprocess the claim then what will be your action?




5. If the claim is denied for denial code - 24 from Medicare/Medicaid payer and you are able to find the managed care information then while billing the claim to managed care insurance, will you keep the Medicare/Medicaid payer as a secondary payer?


6. What could be the possible reasons for the claim to be denied for denial code - 24?




7. If you are working on a claim that has a DOS as 01/20/2024 and the capitation period starts from 01/01/2023 and ends on 12/01/2023 then what will be your action?




8. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid then what will be your next valid questions?




9. If the claim is denied for denial code - 24 from the Medicare/Medicaid payer and rep confirms the managed care insurance, policy ID and mailing address then what will be your action?




10. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid and rep confirms that the patient is not covered under the capitation agreement then what will be your next valid questions?




11. What is Fee-For-Service (FFS)?




12. If the claim is denied for denial code - 24 from a non-Medicare/Medicaid payer and the rep confirms that the patient is covered under the capitation and the DOS lies between the capitation contract period then what will be your action?




13. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid and the rep confirms that the patient is covered under the capitation agreement and the DOS does not lie between the capitation period then what will be your next valid questions?




14. If you are working on a claim that has a DOS as 01/20/2024 and the capitation period starts from 01/01/2024 and ends on 12/01/2024 then what will be your action?




15. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid and the rep confirms that the patient is covered under the capitation agreement then what will be your next valid question?








Share:

10 comments:

  1. Anonymous9 July 2024 at 22:38

    I didnt get the correct answer for question number 8. Can you tell me the correct answer.

    ReplyDelete
    Replies
    1. Anonymous18 July 2024 at 21:48

      A and D

      Delete
    2. AR19 July 2024 at 08:25

      Yes, the correct answer is A and D. You can check the scenario for more details.

      Delete
    3. Anonymous25 September 2024 at 07:04

      Option A does not make any sense if the claim is denied then why will we ask for payment information? Please clarify.

      Delete
    4. Anonymous9 October 2024 at 05:51

      ?

      Delete
    5. AR11 October 2024 at 09:14

      Because when payers other than Medicare or Medicaid process the claims under capitation, they typically provide both the allowed amount and the paid amount.

      Delete
    6. Anonymous14 October 2024 at 09:47

      Thanks!

      Delete
  2. Anonymous2 August 2024 at 00:28

    Hello team,

    what is answer for question 6

    ReplyDelete