IE

Implant Review Essentials

High-Dollar Claim Review · Nurse Education

Lesson Course Assessment

Work five high-dollar claims on your own

This is the graded end-of-module assessment for the Investigational-Implant Review module. Work five simulated high-dollar claims — bundled biologics, a covered cardiac valve, off-label BMP, an IDE clinical-trial device, and an HDE pediatric valve. For each claim, read the language exactly as it appears, flag every line that warrants investigational-implant review, check your flags, then compare your reasoning against the full seven-step walkthrough. Mastery is at least 80% of the required steps completed correctly.

How to use this assessment

Work each claim on your own

Before you begin

Enter your name and work email so your instructor can record your assessment result.

For each claim, read the itemized-bill and implant-log lines exactly as written. Click every line you would flag for investigational-implant review, then check your flags against the expected flags and the worked seven-step walkthrough. Use one printed checklist per claim to score your steps, and keep the policy lookup page open while you work.

Score each claim on the checklist

Print one copy of the structured review checklist per claim and tick off each required step as you complete it. Mastery is at least 80% of the steps completed correctly.

Need the policy language?

Keep the policy lookup page open while you work — it lists each Blue Cross NC policy title and its key determination rule by implant type.

No baseline recorded yet

Take the pre-assessment first if you have not — its score is the baseline used to measure how much the module improved your accuracy.

Course Assessment

Five high-dollar claims

Simulated claim · for training

62-year-old patient, lumbar spinal fusion at L4–L5 for degenerative disc disease. High-dollar facility claim; the itemized bill and implant log extract below show the billed lines most relevant to your review.

Itemized bill & implant log extract

Read each line exactly as written. Click every line you would flag for investigational-implant review, then check your flags.

Finish

Send your result to your instructor

Your assessment result

0 / 0 lines correctly flagged

0 of 5 claims checked

Check your flags on at least one claim first.

Sources

Primary policy references

These are the live Blue Cross NC and FDA pages the assessment claims are built against.

  1. 1.FDA — Implants and ProstheticsVerify the device's approval or clearance and its approved indication.https://www.fda.gov/medical-devices/products-and-medical-procedures/implants-and-prosthetics
  2. 2.Investigational (Experimental) Services — Blue Cross NC commercial medical policyThe criteria your determination is written against, and the rule that associated services are also not reimbursed.https://www.bcbsnc.com/providers/policies-guidelines-codes/commercial/administrative/updates/investigational-experimental-services
  3. 3.Medical Necessity — Blue Cross NC commercial medical policyThe five criteria a service must meet to be covered.https://www.bcbsnc.com/providers/policies-guidelines-codes/commercial/administrative/updates/medical-necessity
  4. 4.Bone Morphogenetic Protein — Blue Cross NC commercial medical policyhttps://www.bcbsnc.com/providers/policies-guidelines-codes/commercial/surgery/updates/bone-morphogenetic-protein
  5. 5.Orthopedic Applications of Stem Cell Therapy — Blue Cross NC commercial medical policyhttps://www.bcbsnc.com/providers/policies-guidelines-codes/commercial/other-treatments/updates/orthopedic-applications-of-stem-cell-therapy
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