Insurance Claims & IA Calls
What are the 3 required elements for an IA Claims Call?
Payer ID Number, Total billed amount, and Date of Service
A fixed amount paid by a patient for a covered healthcare service after the deductible has been met.
What is a copayment (or copay)?
This account is often "use it or lose it," meaning funds must be spent by the end of the plan year, though some offer a grace period or limited rollover.
What is an FSA (Flexible Spending Account)?
A document detailing a client's services, charges, payments, and the remaining balance due to the Group Practice.
What is an Invoice?
What is the critical distinction between a Claims Resubmission and a Claims Reprocessing request, and how does the CCA file each?
Claims Reprocessing must be requested via a claims IA call. Claims Resubmission must be requested via a Claims Ops Jira ticket.
If a client is concerned about a missing claim that was sent 1 week ago, what is the required CCA next step (instead of a Claims call)?
The CCA should inform the client that processed claims data has likely not yet been received because the payer is still processing, and the client will receive an EOB once complete. CCAs are instructed NOT to request a claims call if claims have been sent only 1 week prior.
The maximum amount a policyholder has to pay for covered services in a given plan year.
What is the out-of-pocket maximum?
What spending account is funded solely by the employer?
What is an HRA (Health Reimbursement Arrangement)?
How do Group Practices get paid? Who can see / edit the banking details?
They get paid in a lump sum for all providers, the admins can see the banking & payout details. They determine what each provider gets paid out because of admin / office fees and so on.
If a claim is denied due to Invalid Claim Information (a syntactical error) but has not been denied (e.g., status is "Failed to Submit"), what must the CCA check before escalating to Claims Ops?
The CCA must check the appointment-level claims tab for a "Headway Filing Error" and check the Claim Report Statuses for any specific error messages.
When dealing with a claim denial, what is considered the "strongest tool" a CCA can provide to the IA caller to argue for a denied claim to be reprocessed?
The strongest tool is another claim for the same plan, provider, and CPT that was processed differently (i.e., not denied). This inconsistency is used as evidence to get the denied claim reprocessed.
A term for when an insurance company requires a provider to get authorization before rendering certain services.
What is prior authorization (or pre-certification)?
2 waived sessions and on the general tab in the client's atlas account.
What must you always do with Group Practices?
Use sendsafely to confirm the clients name, DOB, and rendering provider.
What has been Lindsey's favorite food the past 2 weeks?
Tacos from Viva Villa Downtown!!!
What are the macros for IA Benefits Calls & IA Claims Calls?
Insurance Call Request [Step 2—Request Call]
Insurance Call Request CLAIMS SPECIFIC, Step 2—Request Call
The process used on an Insurance Portal to determine if a specific service is covered for a specific patient under their plan.
What is eligibility and benefits verification?
The primary difference between an EAP (Employee Assistance Program) session and a standard session, regarding client payment.
What is the client pays nothing (or the EAP covers 100% of the session fee)?
What are 3 troubleshooting steps we can do if a provider is missing a payout?
Lindsey has 2 dogs, what are their names & ages & breeds?
Duke — 3 year old — Golden retriever
Tucker — 8 year old — Chocolate Lab
Under what specific condition, concerning TPA (Third-Party Administrator) plans, can a CCA request a Benefits call?
The client must have a TPA plan that the CCA has confirmed is listed as Available or Manually Available on Headway using the Insurance Payer Directory. Requests for plans listed as "Unavailable" will be closed out by the IA caller team.
When searching in an insurance portal, what are 3 types of identifiers we should look for when verifying benefits?
Mental Health, behavioral health, psychologist, outpatient, office, facility, specialist / PCP
What are the 4 details we need to confirm Headway was paid through a spending account if we cannot get an EOB?
Date Cleared:
If a provider is paid out $150 for a session, but the client is charged $200, where does the difference go? Please explain the entire billing / payment process.
$200 goes straight to the insurance carrier. $150 comes straight from the insurance carrier to the provider. Headway does not get a cut of the client's payment or the providers payout. Headway has a separate contracted rate with the insurance carrier. 3 paths happening at the same time.
When is a Transition Session Request approved by Benefits & Eligibility Ops for a client who shouldn't have been seen on the platform due to being a Medicare & Medicaid (M&M) client?
The client may be eligible for one waived session (not a transition session), valid for use within 30 days.