Thinking Question's
Does the 365-day timely filing period apply to United Healthcare & Oxford when the provider is calling?
Yes
(UHC & Oxford Timely filing is waived for Member & Client only)
The Member Balance Bill Request Issue type is only used for which clients?
UHC, UHC EPDP, UMR, Oxford, Oxford EPDP, Golden Rule Inc., Rocky Mountain, or Student Resources
How long can you keep an EPDP or Aetna Provider Inquiry in your queue to wait for the signed LOT?
up to 10 business days
How long does it take for a provider to receive access to the portal?
Up to a week
if claim is closed as successful negotiation, can you reopen for review again?
no because our handling is complete on our end
Is the 365-day timely filing rule waived for all Aetna calls?
yes
Aetna Timely filing is waived for all calls.
If there is a Member Balance Bill Request Issue type that is currently open and the member is calling stating, "they have not received the email with the URL link to upload their bill'. What steps would you take?
Verify the email address is correct, have the caller confirm and repeat the spelling back to them.
If the email address is incorrect, update the existing open issue, and correct the email address
Once saved, add a new action “Request Balance Bill” in the open “Member Balance Bill Request”, confirm email listed is accurate and submit (this will resend the email request to the member)
If the provider declines to accept the allowed amount on an Aetna claim, how would you close the issue?
inquiry resolved
provider is stating that they do not want they claims sent to us. Can we stop it on our end? Or what can we say to them?
No
Advise the caller you do apologize but the claims are sent to us by the client/insurance. You will need to contact the client and speak with their internal department to discuss having your claims not sent to us for pricing.
What status should be in your queues c, b, z?
c only
Open a member Inquiry
Auto assign the issue
Provide the member script listed in the NJ surprise bill P&P.
If the patient advocate is calling on behalf of the member, and they are not an approved client per the client specific instructions or per the appeal mgmt. tab. Would you need authorization to speak with the advocate?
yes, A HIPAA authorization is needed.
If you receive a signed LOT back from the provider accepting the allowed amount as payment in full, how would you close your issue?
DIS Provider Accepted Recommendation
After speaking with the provider and you have provided the methodology and stand on data verbiage. Which disposition code would you select in Aspect?
SODMethd- SODMethodGiven –
Stand on Data claim and Methodology was given to the provider on the call.
if there is no savings- lost savings on the claim, can you reopen the claim up again for review?
No, we can't we will refer caller to the client for any additional questions?
What info would you provide if the caller asks to place you on hold?
Advise the caller that you can hold for up to 3 minutes. If longer than 3 minutes, you may disconnect the call. Before hanging up, attempt to make a general statement that you are hanging up due to no response.
Document the reason call was disconnected.
If the patient is calling to provide verbal authorization for their spouse or parent to speak on their behalf for multiple claims. Would you have to document that verbal authorization was obtained on each claim.
Yes, each claim would need to be documented that patient provided verbal authorization for spouse or parent to speak on their behalf.
Also let them know that it is applicable to all the claims that we discuss today.
If the provider declines to accept the allowed amount for a UHC EPDP/Oxford EPDP claim, how would you close the issue
Maximum Allowable Paid
If the provider is experiencing issues with their login information for the online provider portal, what steps would you provide?
Provide the Discustomerservice@dataisight.com email address. Once they submit the email, a ticket will be opened through our support team?
What is the time frame that the TIN has to be in for us to still consider it as Municipal Ambulance?
12 months
Will you use closure types DIS Successful Negotiation or Unsuccessful Negotiation when closing an issue?
No
Only the appeals team (Claims specialist) will use those closure types.
If the member has paid upfront for services & the claim is for UHC & affiliates. What issue type would you use & what document will the member need to upload?
Open issue as Member Balance Bill Request & they will need to upload a copy of the statement/receipt.
If the provider declines to accept the allowed amount on a UHC ASO (non epdp) claim. Would you close the issue as Maximum Allowable Paid or Auto assign the issue for further review?
You would auto assign the issue
For UHC/Oxford non EPDP claims you will forward for a claim specialist to review.
If a provider calls and would like to know how much is allowed 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 not all claims are routed to us.
For UHC member inquiry for a Municipal ambulance claim how would you close it?
BB May occur