Level 1
Payment was sent to incorrect address
1. Verify billing information on File
2. If address incorrect, create Salesforce case or transfer to Provider Services
3. Provider can update in Availity
Disputes the amount of the check
What amount do they disagree with
Direct to Tricare.triwest.com for instructions on Overpayments/refunds, etc
Caller received bill and/or denied claim for unauthorized care
1. Verify Denial Reason
2. If required referral, verify Salesforce for referral
3. Educate caller on using self-service portal
Received check but no EOB
1. Utilize Availity for EOB
2. Submit Salesforce Case with NPI/TIN, date of check and amount
Calling regarding Claim Status
1. Has it been 30 days since submitted
2. Review Salesforce
2. Check Self Service portal
Call about service prior to 1 Jan
Must direct to Health Net Federal Services 18004445445
Calling to check status of Claim
1. Check Availity
2. Has it been 30 days
Caller disagrees with denial reason
1. Educate on reconsdieration process
2. Submit appeal via fax, email or online
3. Must be filed in 90 days
Claim was Rejected/ Returned
Claim must be resubmitted
Has specific questions about denial
Send to PGBA
Calling to inquire on timeline for submitting claims
No more than 365 days
Caller wants to confirm Paid amount
Verify in Salesforce
Submitted Reconsideration with no status update
1. Takes up to 120 days
2. If over 120 days escalate through Salesforce
Requests status of 6 or more claims
You can only assist with 5
Submit online request for claims checks through triwest
Replacement PRA or EOB
Submit case in Salesforce