Course Review – MA/MAPD Member Experience

Practice Activity

Introduction This practice activity will help the learners access member information using
Anthem tools and systems to check a member’s claims. They will look up
claims-related information and answer a set of questions that will manifest their
understanding of the Claims course. They will demonstrate expertise in the use
of Anthem tools and systems for claims research. They will also synthesize
what they have learned by analyzing all the information they gathered to
communicate to the member’s claims concerns.

After the learners complete the activity, they will send completed activities to
your attention. You will provide them with the answer key to help them identify
their level of success.

Activity Type This is an individual self-paced activity.

Getting Started You will need the following to facilitate this activity:

• Outlook
• Lync/Skype
• Training Compass
• Facets
• iHealth
• MACESS
• Link to the Learner Guide

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Practice Activity

Prepare and Complete the following steps to prepare and facilitate this activity.
Facilitate
Step Action
1 Review the items and confirm that all scenarios are still
accurate.
2 Edit the document, if needed, to create an answer key.
3 After the learners send their completed activity through
Outlook, reply and provide them with the answer key.

4 Review learner answers and reply with individual

feedback by email.

Note: Meet one-on-one with a learner if the activity

shows a large learning gap.

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Practice Activity

Practice Activity: Course Review

Directions For each item, follow the instructions listed and answer the questions. After
you finish, email this document with your answers to your facilitator for
feedback.

1 Using the following member IDs, find out more about their claims and answer
the following questions using simple language.

1. Member ID 716658241

a. Who is his PCP?

b. Is the member part of a DRE or DRG? (Yes/No)
c. What is the claim number on the most recent claim listed for this
member?
d. What is the date on the claim?
e. When did we receive the claim?
f. If there was any, what did we pay on the claim?
g. What is the claim status?
h. Was the claim denied? If yes, why?
i. How many lines are denied? What is the common reason or reason
code for the denials?
j. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

2. Member ID 103M78898

a. Who is his PCP?

b. Is the member part of a DRE or DRG? (Yes/No)
c. What is the claim number on the most recent claim listed for this
member?
d. What is the date on the claim?
e. When did we receive the claim?
f. If there was any, what did we pay on the claim?
g. What is the claim status?
h. Was the claim denied? If yes, why?
i. How many lines are denied? What is the common reason or reason
code for the denials?
j. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

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Practice Activity

3. Member ID 806M62723

a. Who is his PCP?

b. Is the member part of a DRE or DRG? (Yes/No)
c. What is the claim number on the most recent claim listed for this
member?
d. What is the date on the claim?
e. When did we receive the claim?
f. If there was any, what did we pay on the claim?
g. What is the claim status?
h. Was the claim denied? If yes, why?
i. How many lines are denied? What is the common reason or reason
code for the denials?
j. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

4. Member ID 718940345

a. Who is his PCP?

b. Is the member part of a DRE or DRG? (Yes/No)
c. What is the claim number on the most recent claim listed for this
member?
d. What is the date on the claim?
e. When did we receive the claim?
f. If there was any, what did we pay on the claim?
g. What is the claim status?
h. Was the claim denied? If yes, why?
i. How many lines are denied? What is the common reason or reason
code for the denials?
j. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

5. Member ID 095M78349

a. Who is his PCP?

b. Is the member part of a DRE or DRG? (Yes/No)
c. What is the claim number on the most recent claim listed for this
member?
d. What is the date on the claim?
e. When did we receive the claim?
f. If there was any, what did we pay on the claim?
g. What is the claim status?
h. Was the claim denied? If yes, why?

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Practice Activity

i. How many lines are denied? What is the common reason or reason
code for the denials?
j. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

6. Member ID 852M68116

a. Who is his PCP?

b. Is the member part of a DRE or DRG? (Yes/No)
c. What is the claim number on the most recent claim listed for this
member?
d. What is the date on the claim?
e. When did we receive the claim?
f. If there was any, what did we pay on the claim?
g. What is the claim status?
h. Was the claim denied? If yes, why?
i. How many lines are denied? What is the common reason or reason
code for the denials?
j. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

2 For each item, use Compass, MACESS, Facets and iHealth and then answer
the following questions using simple language.

Indicate in your answer if you used a specific tool or system, or a combination

of them, to research on the member’s claims concerns (7 points/item).

1. Claim ID 152935291400

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?
g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

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Practice Activity

2. Claim ID 149529910900

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?
g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

3. Claim ID 130876746400

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?
g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

4. Claim ID 150260232500

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?
g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

5. Claim ID 153080196400

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?

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Practice Activity

g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

6. Claim ID 124900705100

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?
g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

7. Claim ID 125351705800

a. When did we receive the claim?

b. What did we pay on the claim?
c. What is the member responsibility (in terms of deductible, copay or
coinsurance)?
d. What does the DOFR form notes is the status of the claim?
e. Was the claim denied? Why?
f. How many lines are denied?
g. If you were speaking to this member now, what would you say to
communicate to the member’s issue?

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Practice Activity

Document Statistics

Copyright Anthem, Inc. © All rights reserved

Publishing Document Type Practice Activity

Data Object Store
KL Content ID
Content Owner Learning and Development

Revision
History Version # Date Nature of Change
9 Summary:
Author:
8 Summary:
Author:
7 Summary:
Author:
6 Summary:
Author:
5 July 4, 2018 Summary: Ready for review
Author: Pia Saavedra
4 June 29, 2018 Summary: 2nd Review
Author: Maryhelen Benavente
3 June 13, 2018 Summary: Updated per CQA
Author:
2 June 1, 2018 Summary: Updated copy
Author: Pia Saavedra
1 May 23, 2018 Summary: Initial build
SMEs: Micki Jones-Holloway
Author: Pia Saavedra

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