Insurance
What are the site responsible insurances for obtaining benefits?
ALL
What do you set the start date to on a new 2025 referral
1/1/2025
Do I have to verify ALL demographic information in the registration if a patient is continuing into 2025?
Yes
Who is required to sign a new consent form?
All new patients and patients changing insurance in 2025
What information is required when obtaining benefits?
Calendar Year or Contract Year
Deductible amount, Deductible amount met
Coinsurance amount/Copay amount
Out of Pocket amount, Out of Pocket Met
Visit limit, Visits Used
Authorization guidelines
Referral guidelines (insurance or paper referral required)
Can the patient self-refer
Representative’s name and the reference number for the call
What are the site responsible insurances for obtaining authorization (for sites with a CPSR)?
Medicaid, Wellcare, Optumcare (Anthem, UHC, Connecticare, APN plans), UHC Managed Medicare, Unicare, Cigna-Speech, BCBS Capital Blue, VA, Tricare-East & Active Duty, Anthem (MTN prefix)
What scheduling status should the 2025 referral be set to?
HHCRN End of Year Benefit Review
What is RTE?
Real Time Eligibility
What will be needed for a patient with new insurance?
1) New Benefit Form for the year
2) New A + A (Consent Form)
3) Scan new insurance card(s) into Epic
*labeling as new insurance
4) New referral (with status HHCRN End of Year)
5) Scheduled as a new Evaluation
What's the difference between Calendar Year vs Plan Year(Contract Year) benefits?
Calendar Year plans run from January 1st of the year to December 31st of the same year.
Plan Year/Contract Year plans run from the effective/start date of the plan until 1 year later (ex: plan starts 06/01/2024 and ends 05/31/2025)
A Workers Comp patient's referral is set to expire 12/31/2024, what are the next steps?
1) Determine if an End Date Extension is appropriate
2) If reauthorization is needed, obtain an updated script or signed POC, set referral to 500s/pending/not enough info, scheduling status to "HHCRN Pending Reauthorization"
A patient with Medicaid does not require authorization, do they need a referral? Explain your answer
No, change the current referral end date to 12/31/2025
After running RTE, how do I verify the plan information within Epic?
Response History (in the registration as well as the referral)
A patient's insurance and ID number are not changing for 2025. What will the next steps be?
1) schedule appointments as treatments as normal
2) create a new referral with start date 1/1/2025. changing scheduling status to HHCRN End of Year and adding note in communication section "2025 referral"
3) obtain 2025 benefits and add them to the communication section, benefit grid, and benefit collection notes
Patient has authorization through 1/20/2025, but their plan runs on a calendar year. Do they need a new 2025 referral/benefits?
No new referral is needed, however 2025 benefits will still need to be obtained and documented appropriately
If there's a plan mismatch or content error within EPIC, who is responsible for correcting the error?
The site PSR
What insurances require a new Referral for 2025?
All insurances that are no authorization required and run on a calendar year except for Workers Comp, MVA and Medicaid
What do you do if RTE returns as E-Rejected?
Verify with the patient the insurance on file is accurate-
-If not, update the new insurance, schedule a new eval, obtain new benefits
-If yes, call the insurance to verify eligibility and benefits for 2025
A patient's insurance terms 12/31/2024 and they tell you they'll have no new coverage in 2025. What will be needed at their next visit?
Self-Pay Letter, Estimate, new 2025 referral
When obtaining benefits, they state that authorization is required. What additional information do you need to find out?
How to submit authorization (including contact information if needed)
The patient's insurance plan is staying the same, but their ID number is changing in 2025. Do they need a new evaluation?
A call would need to be made to the insurance plan to verify if a new evaluation is required
When copying a patient's referral is it ok to hit accept or will any changes need to be made? Explain your answer
Will need to change the status of the referral to "pending"/"not enough information," change the counters to 99, add a note "2025 referral," change scheduling status to "HHCRN End of Year Benefit Review" before hitting accept
A patient has a new Aetna Managed Medicare starting 1/1/2025, can I add it on 12/13/2024?
Yes, but since the insurance will not be active until 1/1/2025-
-If the patient does not have any other active coverage, mark the patient as self-pay/do not bill
-If the patient does have active coverage, please be sure to add an end date to their primary plan to 12/31/2025
Add a note in the referral about the new coverage
A patient has authorization that ends 2/13/2025 with 6 visits remaining, but their plan ends 12/31/2024 and they say they'll be on the same plan in 2025. Will they need a new 2025 referral?
No, just verify the insurance and benefits for 2025 commented in Epic under benefit collection and the communication/notes tab in the referral titled 2025 benefits
A patient has Medicare and a secondary BCBS commercial plan. Do we need to obtain benefits for the secondary plan?
Yes - all secondary or tertiary benefits need to be obtained as commercial plans do not always follow Medicare guidelines