Course Review – MA/MAPD Member Experience

Practice Activity

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

Your facilitator will review your answers and comment after you complete the
activity.

Activity Type This is an individual self-paced activity.

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

• Outlook
• Lync/Skype
• Training Compass
• Facets
• iHealth
• MACESS

Request Help Your facilitator is available to help you if you encounter any issues. Reach out to
the facilitator using Lync/Skype.

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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)

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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?

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?

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Practice Activity

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?

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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?

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).

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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?

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?

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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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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

Next Steps Congratulations on completing the End of Course – Review! You are ready
to send your completed activity to your facilitator for review and comments.

Tip: Save the documents to have a personal copy to look at later.

Complete these steps to send your completed document to the facilitator.

Step Action
1 Using Outlook, create an email addressed to your
facilitator.
2 Attach copies of the completed document to the email.
3 Type End of Course – Review (EOM) in Subject.

Note: EOM stands for End of Message. Typing a

message to the facilitator is optional.
4 Select Send.

Result: Outlook sends the document to the facilitator

within approximately 5 minutes.

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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
SME: Maryhelen Benavente
3 June 13, 2018 Summary: Updated per CQA
Author: Pia Saavedra
2 June 1, 2018 Summary: Updated per POC
Author: Pia Saavedra
1 May 23, 2018 Summary: Initial build
SMEs: Micki Jones-Holloway
Author: Pia Saavedra

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