Tricare & VA Coverage

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TRICARE:

  • It covers active and retired military personnel and their dependents, survivors and certain former spouses.

VETERANS AFFAIRS / ADMINISTRATION (VA):

  • Veteran - Veteran is a person who has served in the army, navy or air force, especially during a war.
  • It covers the spouse or child of a veteran who died on the duty or who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.

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B20: Procedure/service was partially or fully furnished by another provider

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Denial Occurrence:
  • This denial occurs when multiple providers billed the same service on the same date of service.
  • The providers can be part of same or different Group/Facility/Hospital.

On Call Scenario:

                                         Claim denied as it is already paid to another provider
                                                                              ↓
                                                            May I get the denial date?
                                                                              ↓
                                     Check in system if the same service on the same DOS
                                     has already been billed and paid to another provider
                                                   ↙                                                    ↘
                                             Yes                                                         No
                                          ↙                                                                    ↘
                         What is the time                                    Could you please provide the name
                       frame for  to submit                                  and NPI of the provider to whom
                       the corrected claim?                                     the payment has been made?
                                     ↓                                                                           ↓
                          May I have the                                                 What is the Fax# or
                       claim# & call ref#?                                              Mailing address to
                                                                                                      send an appeal?      
                                                                                                                  ↓
                                                                                                      How much is the
                                                                                                           time limit?
                                                                                                                  ↓
                                                                                                       May I have the
                                                                                                   Claim# & Call ref#?

Important Notes & Actions:
  • Please take action as per your process update. Below actions can be different from your process update.
  • If you find the same service on the same DOS under a different provider in your system then you can submit corrected claim after appending 77 modifier.
  • If the payer is Medicare then do not need to submit corrected claim, you can append 77 modifier and resubmit the claim.
  • If you do not find the same service on the same DOS under a different provider in your system and it is part of different group then you can send an appeal to insurance.
  • Sometimes, clients wants to write off such claims. So, work as per client instructions.
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TFL & AFL Calculator

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Scenario Based Quiz - Capitation Agreement / Managed Care Plan

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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?








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Scenario Based Quiz - Duplicate Service

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1. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different and the rep agrees to reprocess the claim on probing then what will be your next valid question?




2. If the claim is denied by non-Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are the same but the exam times are different then what will be your action?




3. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different but the rep denies to reprocess the claim and ask to send the corrected claim then what will be your next valid question?




4. If the claim is denied by Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different then what will be your action?




5. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and modifiers on both the charges are different and the rep denies to reprocess the claim and ask to send an appeal then what will be your next valid questions?




6. If the claim is denied by non-Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different then what will be your action?




7. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the CPT is billed once only on DOS then what will be your next valid question?




8. If the claim is denied by Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are the same but the exam time are different then what will be your action?




9. If the claim is denied by Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and both are exact duplicates then what will be your action?




10. If the claim is denied by the insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different but the time frame to submit the corrected claim has been crossed then what will be your action?




11. What are the possible reasons for the claim to be denied as Duplicate service?




12. If the claim is denied by the insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS but the modifiers on both the charges are different and the rep denies to reprocess the claim and asked to send an appeal then what will be your action?




13. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the CPT is billed once only on DOS and the rep provides the original status as the claim is paid to the provider then what will be your next step?




14. If the claim is denied by the insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS but the modifiers on both the charges are different but the rep denies to reprocess the claim and asked to send an appeal and the time frame to send an appeal has been crossed then what will be your action?




15. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and rendering providers on both charges are different then what will be your next valid question?








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Scenario Based Quiz - Primary Paid More Than Secondary Allowed Amount

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1. When does a CPT get denied for denial 23?




2. If you receive the status on call as the claim is denied as the primary paid more than secondary allowed amount and you find that the primary insurance has paid less than the secondary allowed amount then what will be your next valid questions?




3. If the claim is denied as the primary paid more than secondary allowed amount and you find that the primary insurance has already paid more than the secondary allowed amount then what will be your action?




4. If the claim is denied as the primary paid more than secondary allowed amount and you find that the primary insurance has paid less than the secondary allowed amount and the rep agrees to send the claim back for reprocessing then what will be your action?




5. If a CPT with a billed amount of $100.00 is denied by primary insurance for denial 23 then what will be your action?




6. If a CPT with a billed amount of $150.00 is allowed by primary insurance for $40.00, paid for $30.00 and patient responsibility is $10.00 as coinsurance. For secondary insurance, the allowed amount for the same CPT is $35.00 then how much amount will be paid by secondary insurance?




7. If a CPT with a billed amount of $200.00 is allowed by primary insurance for $60.00, paid for $45.00 and patient responsibility is $15.00 as coinsurance. For secondary insurance, the allowed amount for the same CPT is $60.00 then how much amount will be paid by secondary insurance?




8. If a CPT with a billed amount of $250.00 is allowed by primary insurance for $80.00, paid for $64.00 and patient responsibility is $16.00 as coinsurance. For secondary insurance, the allowed amount for the same CPT is $64.00 then how much amount will be paid by secondary insurance?




9. If a CPT with a billed amount of $130.00 is allowed by primary insurance for $35.00, paid for $0.00 and patient responsibility is $35.00 as Deductible. For secondary insurance, the allowed amount for the same CPT is $35.00 then how much amount will be paid by secondary insurance?




10. If a CPT with a billed amount of $170.00 is allowed by primary insurance for $50.00, paid for $20.00 and patient responsibility is $30.00 (Deductible - $20.00 and Coinsurance - $10.00). For secondary insurance, the allowed amount for the same CPT is $20.00 then how much amount will be paid by secondary insurance?








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Modifier Based Quiz - Part 2

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1. When an operating physician plans to perform a surgical procedure alone but during an operation, circumstances may arise that require the services of an assistant surgeon for a relatively short time then which modifer is used by the assistant surgeon to report the surgical procedure?




2. When a service is performed repeatedly on the same day by different physicians then which modifier is used with repeated service to get it reimbursed?




3. When an assistant at surgery services is provided by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) then which is used by the assistant surgeon to report the service?




4. When 2 distinct services are performed on the same day and both are independent of each other & performed on 2 different body parts then which modifier is used to indicate both these services are distinct and separate procedures?




5. When an assistant surgeon assists a primary surgeon and is present for the entire operation or a substantial portion of the operation then which modifier is used by the assisting physician to report the surgical procedure as the operating surgeon?




6. When surgery is performed on a patient and during the postoperative period, an E/M service is performed that is not related and included in the surgery then which modifier is used with the E/M code to bill it separately?




7. When a physician does not perform the service completely & reduces or cancels it before completion then which modifier is used to identify the service is reduced?




8. When a service is performed repeatedly on the same day by the same physician then which modifier is used with repeated service to get it reimbursed?




9. When an assistant at surgery service is provided by an MD since there is not a qualified resident available then which is used by the assistant surgeon to report the service?




10. When a physician needs to perform major surgery and an E/M service is given on the same day or a day before the surgery then which modifier is used to reimburse E/M service?








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