Balance Billing
What is balance billing?
When providers charge patients for covered services more than their contracted or allowed rates.
In what scenario would MET take the call for Minor Web Registration?
The appropriate documentation has been received, and the caller insists on staying on the line to complete registration for a minor.
What Mentor would we use to confirm if MET handles BH, or if the vendor does for a specific state?
CAS Mental Health List Medicaid and MMP
Which Mentor(s) would we use to verify mbr in a FL IPA?
(starting from: Medicaid Escalations Team Document Index)
-Delegation Overview
-Members Affiliated with a Delegation (if applicable)
What is the scenario when MET would take the call & which Mentor tells us this?
The provider states they won't accept the member's Medicaid or MMP plan, even though they're showing in network in Find Care, Find a Doctor or PAAG.
(In and Out of Scope Call Transfer to MET Overview Medicaid)
What Mentor would we use for a FL LTC member who states they are being Balance Billed?
Balance Billing for Florida LTC
What is the required documentation for MWR?
Humana must receive both to be approved for Minor Web Registration:
1. A letter of authority with the following required information:
- They're the legal guardian of the child
- They have authority to open a Humana.com account for the member
- The child's name, date of birth, and Humana ID
2. A copy of 1 other document from the following list:
- Certified birth certificate
- Divorce decree
- Legal guardianship paperwork
- Medical support order
For the states that Humana/MET is the BH Vendor (Per CAS Mental Health List Medicaid and MMP), what issues/questions do we assist with?
-Authorizations/precertification- with CIT/online portal per state guidelines.
-Claim processing and questions
-Provider verification
-VOB
-Grievance & Appeals
What issues/questions do we assist with regarding those FL IPA members & which Mentor would we use to tell us this?
MET handles:
-Claims
-Authorizations
-Referrals
(Per: In and Out of Scope Call Transfer to MET Overview Medicaid)
Which Mentor(s) would we use to assist with In Network issues/PAR Provider not accepting (depending on situation)?
(Starting from: Medicaid Escalations Team Document Index)
-MET Provider Verification Discrepancies
-Initial Provider Search
-Kentucky Medicaid Provider Requests Member Disenrollment for MET
What Mentor would we use for an IL MMP member who states they are being balance billed?
Balance Billing for MMP
What team/dept would we reach out to for assistance with registering Minor Web account?
Access Management & outreach needs to be made before 6pm (which is when that team leaves)
If mbr is an IN Pathways for Aging mbr, which mentor would we use to handle call?
(Starting from: Behavioral Health Incoming Calls Overview Medicaid Escalations Team)
Behavioral Health Incoming Calls Overview Indiana PathWays for Aging
What is OUT OF SCOPE for MET for FL IPA members & which Mentor would we use to tell us this?
-Demographic changes
-PCP changes
-Ordering ID cards
-Verification of benefits
(In and Out of Scope Call Transfer to MET Overview Medicaid)
Which system(s) would we use to verify if a specific provider is not accepting Humana?
Which Mentor would we use to assist with call handling?
-Find Care / PFP
-PAAG (If applicable)
(MET Provider Verification Discrepancies
What Mentor would we use for an ALIGNED or INTEGRATED plan member who states they are being balance billed?
Balance Billing Overview
What application would we use to verify/download the required documentation?
Humana Image View Station
Find the case with classification WEB MOBILE with DCN image link (it will be a hyperlink) & copy DCN & paste it into Image View Station, then save to PC for uploading in ticket.
Which Mentors would we use to verify if a member is an OHIO Rise member?
(Starting from Behavioral Health Incoming Calls Overview Medicaid Escalations Team)
OhioRISE Medicaid Overview
OhioRISE Call Handling for Behavioral Health (MET) Team
(Bonus: Self Service- OhioRISE Website)
How do we confirm if a mbr's provider is in a FL IPA & which Mentors would we use to assist with this?
-Contact Handling alerts
-The grouper number on the PCP page in CRM matches the grouper number in the Source of Truth.
-The grouper number can also be found in Debut under Account Details.
(Delegation Overview & Members Affiliated with a Delegation)
If we have a call from a mbr, who states their provider isn't accepting their Humana plan, but we verified provider's location was INN per Findcare/PFP or PAAG, what's the next step?
(Which Mentor assists us with call handling?)
Call provider to see if they are willing to see mbr.
If provider is willing:
- Tell the caller that the provider is willing to see them.
-Provide the name of who you spoke to at the provider’s office.
*Note: You can consult transfer the caller directly to the provider, if appropriate.
(MET Provider Verification Discrepancies)
What Mentor would we use for an UNALIGNED or MEDICAID only member who states they are being balance billed?
Balance Billing for Medicaid
MyHumana Account Lockout Form
TRUE OR FALSE-- The Humana BH queues take calls/questions from providers.
Per: CAS Mental Health List Medicaid and MMP)
FALSE.
-If the caller is a provider and the table indicates that the Behavioral Health team handles the inquiry, transfer them to CCC Provider.
-If a vendor handles the behavioral health inquiry, advise the provider to contact the vendor and provide the phone number.
What resource/application would we use to verify if mbr's provider is in the IPA/ who handles claims, auths, etc?
Which Mentor tells us this?
Delegation Source of Truth
(Members Affiliated with a Delegation)
If after calling provider, and they are unwilling to see member what is our next step & Mentor doc for call handling?
(If we are unable to find another INN provider)
1. Complete Par Provider not accepting Template in CRM
2. Tell the caller that more research is needed to determine the provider's status. (The research time frame is 2 business days.)
3. Case should auto route, but if it doesn't- route it to:
Service Center: Market
Department: National Network Ops
Topic: (Will vary by state)
(MET Provider Verification Discrepancies)