Direct Guidelines
The PIA can identify directs for this client as long as they are not under the federal code guideline; Those have to be sent over to Anita Nelson for look up.
Who is Aetna?
This client will process fees with a copy of the cancelled check if we are able to obtain it.
Who is Oscar?
What two items must have happened in order for your to get a split on cash recovery?
What is the first letter sent and valid contact made?
This list is located under this prompt and provides us with different codes for clients.
What is the client code list?
These three headings can be found under this prompt on the Wiki.
What is how to locate a retractable provider, provider requested retractions, and retraction statuses?
There is not direct process for these three clients; you just place the claim/invoice into direct pending and the finance team reviews. Make sure you have a copy of the cancelled check or check details before placing into direct pending.
Who is Centene, Fidelis Care, and Healthnet?
This is the only client that the PIA has to reach out to QO on once they have confirmed retraction in the client system. We must have the primary EOB on file to get fees.
Who is MMOH?
If a provider advised that they are a non-participating provider with Medicare, for invoice over $1000 that are with commerical carriers, what must the provider do in order for us to close down the request?
The following 5 supporting letters can be found under this prompt on the Wiki.
What is the Medicare Pre entitlement billing, payment methods, Split bill, timely filing and Cigna No recoup letters?
You can verify that a provider is a retractable provider by clicking the claims details button and clicking on what tab and finding the retractable provider section.
What is the provider tab?
For this client, we must send the claim over to ACT product support so they can identify if a direct has been received. If they are able to identify one, they will place it on the GEHA allocation of funds spreadsheet or request the PIRA to have the remit processed.
Who is GEHA?
Once you have reached this number of days you should have the PIA look for the direct once more for Kaiser. If not direct has still posted, you would reach out to your TM regarding your invoice still being on the lost directs spreadsheet with no response.
What is 60 days?
If the provider sends us an EOB and the amount applies to the coinsurance/deductible but only leaves a refund of less than $100, what can we write the invoice off for?
What is coinsurance/deductible write off code?
What is Aetna?
What is Retraction submission?
This time frame is set into place to allow time for clients Aetna, Medica ( not COSMOS ), Kaiser, Tufts and Christus Health to receive checks and place direct information into the client system. We must wait this allotted time before checking for a direct with the client.
What is 30 days from the day the check as sent?
These Cigna directs are sent over to Brian Bevins when we are showing what two items to be completed in the client system. These will be confirmed by the ARDdirects mailbox.
What is the adjustment and check image?
This practice is the best practice to use when a provider tell you that the PI does not offer out of network.
What is the OI call?
For these states, a credit balance is not needed to request a refund if Medicare is primary or if the client is a self insured ERISA plan; Other wise a balance is needed to request a refund.
What is Texas and Maryland?
For provider requested retractions, this needs to be written off first if the claim has been paid, before we send it to retraction.
What is the secondary responsibility?
If a PIA shows a provider's direct posted in the client system, how long should you wait to see the claim has flipped to see if it needs to be added to the lost directs spreadsheet for Kaiser?
What is two weeks?
These Cigna directs must have a CO ticket because what is missing from the client system to process?
What is the adjustment?
This is the practice we use when we receive a bad address letter from Lorrie Lee or in our images for an invoice.
What is reassign the file to your self and contact the provider for correct mailing address?
This letter can be printed by the PIRA to notify the provider that a request has been withdrawn and a refund is no longer due on the claims.
What is the error letter?
These two statuses are the only statuses that can be changed by the PIRA after they have been sent to retraction for the client.
What is the retraction review and the retraction notice sent?