Closure Outcomes
For a BB may occur closure - Do the claim get sent back to the insurance? Or do we just send and Update to the client.
We only send an Update to the client.
Is Aetna Provider call a stand on claim that you would work from start to finish.
yes, it is.
If the provider states they do not want a callback, or refusing the discount or do not want to Negotiate, we respond:
“I understand you are frustrated, but I am escalating for a callback to one of our specialists who can provide you with more details around the pricing and assist you with your questions.”
Provider – verify we have the provider contact information. Inform the provider that we already have a member inquiry that is being handled.
Follow steps to open a Provider Inquiry per client guidelines. Close Internal Resolution documenting the inquiry will be handled through the existing Member Inquiry.
if a provider accepts and sign the LOT for an Aetna claim, what closure would you use?
provider accepted the DIS Recommended allowed amount.
For a Max allowed closure. If you see that we didn't speak to someone on the previous issue, do you open a new issue for review? Also do we send the claim back once its closed as Max allowed or just and Update.
yes, we do because we didn't speak with anyone the first time. We only send an update back
IS UHC EPDP, Oxford EPDP a stand on claim you work from start to finish.
yes, it is
If a member paid up front, will the insurance reimburse them?
We would have to refer you back to your insurance company to ask about reimbursement. At Data iSight we do not have access to your plan benefits. We can however, open an issue up to review the claim with the provider to see if we can get them to agree to a reduced bill charge.
when a provider calls in on an already open provider inquiry would you add an action or open a new issue?
add ana action
If a caller calls and want to escalate a call what is the steps you take?
try deescalating it.
request permission to continue to assist.
if they refuse assistance send an email to lead and supervisor for a call back. Make sure to collect contact information to call back.
successful negotiation do we send this claim back to the client for reprocessing?
yes, we do because there is a change to the repriced amount.
Is Meritain a stand on claim you work from start to finish?
No its not. If they don't accept offer you auto assign
The provider is saying he/she was paid less than the allowed amount and is inquiring about the
Remaining payment?
When the allowed amount is accepted this does not mean additional payments will be made to the provider. The provider will need to direct questions about payments to the client.
If the caller is a Mi and they are calling in to check status. You check claim and see that it is close. Would you open and issue or add an action to the close claim?
open a new issue.
in what box on toolbox will it show that the claim is a NJ Surprise bill?
Claim indicators
Inquiry resolve for Aetna PI closure- would you reopen the issue again if the provider calls back wanting it reviewed again?
Only reopen if they are willing to accept the DIS amount. If they are not, then don't reopen for review again due to no changes to the claim DIS allowed amount.
If the decision maker is not available, do you work the stand on claim from start to finish?
no you ask if they are available. and if they are not then you auto assign
If a provider calls and would like to know how much we allow for a service before they actually
See the patient.
We are not able to provide any information upfront before receiving the claim from the
Insurance. Each claim is handled on a claim by claims basis, and all claims are not routed to us.
if no inquiry is open and caller is calling in would you open a new issue or no?
yes open a new issue
If claim has zero savings, past timely filing, or they just have general question. when opening an Issue what closure would you use?
Internal resolution
unsuccessful closure do we send claim back for reprocessing? Also, can claim be reopen for 2nd level review again.
yes, because the DIS amount has changed. also, no we can't send back for review again.
if you see a UB claim, do you auto assign or work from start to finish????????
no you auto assign
The provider is asking for something in writing when we refer them back to the client.
Unfortunately, we do not have anything to provide in writing. Please contact the insurance and let them know you have spoken with me at Data iSight, and that you would like to discuss any additional appeal options.
if there is already a member inquiry open and the client calls, what steps do you take?
Client – Follow steps to open a Client Inquiry per client instructions.
Inform the client that we already have a member inquiry that is being handled. Provide status of existing open Inquiry. Manually assign the Client Inquiry to the associate that is handling the open Member Inquiry. Associate will document and assess which inquiry remains open until complete resolution / closure.
what client do we use the member bb request issue type for?
UHC, UHC EPDP, UMR, Oxford, Oxford EPDP, Golden Rule Inc., Rocky Mountain, or Student Resources