Insurance Team Work Flow
How far out should you be working your plan?
As far out as you can; ideally working out the amount of scheduled days the plan allows.
Example: BCBS MN - 4 days, Cigna 2 days
How do we run an estimate for Eau Claire?
1. Location in RIS and IM both need to reflect Eau Claire location.
2. Run estimate as you normally would.
Where can you find the list of exams/procedures that always need a waiver?
In MKB - under the non-covered services tab
Patient has Medicare/Medicare replacement plan. What options do they have with Chiropractor referring?
1. Obtain MD order
2. See Rayus pain care department
3. Sign ABN or non covered service waiver and pay full contracted rate at time of service
When should you call patients to rescheduled when authorization determination is still pending, and why?
Between 12-3 PM
We need to give patient's time to call their insurance company/referring office once they are aware of case status.
How do we obtain pricing for ASC exams?
Email the price estimate team.
Options for patients who are out of network with Rayus but have out of network benefits available
1. Patient can pay full self pay rate at time of service and sign insured self pay waiver.
2. Patient can wait for authorization determination from health plan and utilize out of network benefits.
Who and what services are covered under the RAYUS associate scan?
1. PT and FT Employee, spouse and dependents under the age of 26.
2. Imaging exams only. Office visits, injections and vascular procedures are not covered
When is it ok to cold transfer a patient?
Never. We must always warm transfer patients - whether transferring to someone on our own team or a team member in a different department.
What information should be included in your documentation when entering a price estimate?
1. Name of exam
2. CPT code
3. Estimate (will need individual estimates if patient has multiple procedures)
4. Waiver information if waiver is needed
Waiver and amount we offer to patients when a case has been denied
Patient can sign non-covered service waiver and pay full contracted rate at time of service.
What is our process when a case has been denied?
Document in RIS case has been denied - include WHY case was denied in your documentation.
Call referring office to inform of denial ASAP and see how they would like to proceed. Offer P2P/appeal options.
Call patient and inform case has been denied ASAP.
If case is still pending - can patient keep appointment and pay out of pocket for the exam?
No, we must have authorization or denial on file before being able to see the patient.
What estimate do we give a patient when there is no contracted rate listed?
Self pay estimate.
If it is an insured we are contracted with - we can email pricing team for an estimate.
Options when patient is out of network and has NO out of network benefits
Patient can self pay in full at TOS and sign insured self pay waiver.
Email Headline:
1. MRN
2. Patient Name
3. RAD initials/Name
*When emailing RAD assistants - include all necessary documents (denial letters ect.)
DAILY DOUBLE
What do we do work flow wise in each of these situations
1. Imaging for a Cause
2. MN Occupational WC
Do we give out estimates patients who are billing to an auto claim?
No we do not give out pricing information to auto patients. If they are insistent - we can give RETAIL rate for the exam.
If patient refuses to wait for insurance determination or does not want to utilize their health insurance. What options do they have?
HIPAA Restriction Waiver. Patient will need to pay full self pay amount at time of service.
Where can you find all of our current contracts and research studies we have with referring offices?
Under MN Twin Cities MKB
- Research Studies