Submissions skills 1
If the client's name on the IDR notice does not match what is in Employee Portal what process do you follow?
Other Payor
When can you do an advance search for Cigna?
If EOB/EOP is attached to the case.
BCBS TN:
If the claim was not located In CEP what Child CCode do we use?
BCBT OPNCOF
Are all Cigna claims now contracted by Claritev?
Yes- All CIGNA CLAIMS ARE HANDLED BY CLARITEV.
For Cigna when to object for State?
If the NPIC starts with a state abbreviation or the child code is listed below, object.
GREAT IFP
GREAT IFPPPN
GREAT IFPTX
GREAT IFPTXTDI
Do we follow the Misdirect process for VCU submissions?
No. Claritev owns these and will treat these as we would a Sentara submission.
See All Clients Wiki
If the client is Cigna and the claim hold for a pending EOB has already been completed, and you are now finishing the case, can you simply attach the EOB in CMS as is?
No, you have to redact the EOB to block out the HIPPA listed
BCBS MA:
If the claim was not located in CEP what Child CCode do you use?
Enter the default client code in the Child CCode field: BCBSMA NCOFIDR
Which Claim numbers within Cigna needs to be converted?
Only Cigna East claim numbers will need to be converted.
If the claim is not located in the Employee Portal, Is the Proof of Cooling Off Period valid to use?
No, it's not try going to the Timing Wiki to determine if a timing objection applies
For BCBS of Arkansas when do you not use the objection Contracted?
If the Client Code is listed below, review the Provider tab.
AKBCBS HOSTITSAAPPN
AKBCBS HOSTNONAAPPN
AKBCBS HOST ITS QPA
AKBCBS FEPAAPPN
AKBCBS FEPNONAAPPN
AKBCBS FEP QPA
If the TIN is listed below, this objection does not apply. Review all other objections to see if they apply.
Cabot Emergency Hospital TIN: 824121998
Fort Smith Emergency Hospital TIN: 862211233
How many cases you have to complete a day?
28
Horizon:
If the claim is not located in CEP what Child CCode should you use?
HBCBS OPNCOF
If the claim is not located in Employee Portal which claim number, do you put in Service Cloud?
The claim number on the Notice of the IDR Initiation form not the converted claim number.
When do you follow the Bulk Claim Import process?
This process should be followed when a task does not route through automation and additional claims must be imported.
How many cases you have to complete in hour?
4
If state applies as an objection, do you need to look for any more objections.
No other objections are needed.
Horizon:
What number needs to be removed when searching claim number in Employee Portal?
NA780 or 780
If the claim was not located which client code do you use?
Parent CCode: CIGNAHCP
When do we follow the Misdirect Process?
he client is not listed on the Federal NSA Client Profile Tracker or the client is listed, but does not utilize Claritev for IDR services.
Allied Benefit Systems: Claim is not located in the Employee Portal, or claim is located and client code is not ADB QPA or ADB QPANEG.
Rocky Mountain Health Plan (RMHP-P): Claim is not located in the Employee Portal and the Location of Service listed on the Notice of IDR Initiation is not CO (Colorado).
Humana: Claim is not located in the Employee Portal, or claim is located and client code is not COP PPHUMPPN.
Tres Health: Client listed on the Notice of IDR Initiation or EOB is Tres Health.
Fringe Benefit Group, Inc.: MultiPlan verbiage is not listed on the EOP.
Cigna: Employer Group Name is Boilermakers.
Kaiser: Date of service was prior to 04/22/2022 or service code disputed is Air Ambulance.
Is Anthem an IDR Client?
NO
What do we confirm by checking Timing Objection?
The Open Negotiation process was completed correctly.
The dispute was started within the allowed timeframes after the negotiation period.
The dispute was not submitted too early or too late based on the rules.
If the dates do not meet the required timelines, then a Timing Objection applies, and the dispute may be ineligible to proceed.
Horizon:
When do you need to do client outreach?
Client code is HBCBS PPNINE and additional documentation is needed:
Client code is HBCBS ITS or the claim is not located in the Employee Portal:
Next Steps state that client outreach is needed:
If claim is due same day and you have not received the EOB for the NCOF which objection and scripting, do you use?
Insufficient funds and the NIP scripting
When updating the CMS submission form does it need to be viewable for the client?
Yes