Process Handling 1
For United healthcare do we have 365 days timely filing that we follow for providers calls
YES
what client do we use this issue type for
UHC, UHC EPDP, UMR, Oxford, Oxford EPDP, Golden Rule Inc., Rocky Mountain, or Student Resources
if you are not speaking with the decision maker, do you auto assign or keep to self
auto assign
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
For Aetna calls is the 365 timely filing day rule waived for all inquiries
Yes
If the member calls in and state that they haven't received the Email with the URL link to upload their bill. What steps would you do?
1st step check to see if the email is correct
2nd if it is checking the portal tab to see if it is still active
3rd ask them to check their spam and trash folder
4th if they still can't find it resend the link in the action drop down and select Request BB
make sure to advise them what email the URL lik will be coming from
For Aetna provider if they don't accept offer what closure will you use
inquiry resolve
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.
When the Mandated TIN is within the 12 months do we auto assign, or manual assign to Brittney?
manual assign to Brittney
for NJ surprise bill if they don't accept the offer what appeal options will you give the provider. what closure do you use?
EmailNJ_outofNetwork@uhc.com
Certified mail via the address on the back on member id card
Web from https://www.uhcprovider.com
Inquiry resolve
do we use this issue type for Aetna
no
for UHC EPDP and Oxford EPDP what closure will use if they dont accept the offer
max allowed
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 specialist who can provide you with more details around the pricing and assist you with your questions.”
if there is no savings- lost savings, do you open claim up for review
no
What claims do we work as stand on? Would you work them from beginning to end?
Oxford EPDP, UHC EPDP and Aetna
yes, from start to finish
Will the action request bb automatically send or do we have to send it
automatically send
how long can you hold stand on claims in your que
10 days
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 client
if there is a member inquiry closed as bb due to provider is state mandated. How would you handle the call if member calling in for status?
provide the state mandated verbiage open an MI and close as inquiry resolve
if claim is closed for a Member inquiry and the member calls in only to check status. How would you work it from start to finish.
provide the member with the detail outcome and open a MI and close as internal resolution
If a client calls in with the member on the line or back line, would you open a Member BB request issue type?
open MI
If you get a counteroffer would you close the claim as provider accepted or inquiry resolve for Aetna
inquiry resolve.
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.
For meritain if they state on the call that they accept the dis amount but never send in OLOT. how long can you hold it in your que
1 business day