Special Insurances/Special WC Insurances
LIST THE TWO TYPES MILITARY INSURANCE POLICIES
1. Optum VA-CCN (Veterans Affairs-Community Care Network)
2. Tricare East (Prime)
SLIDE: 113
What is the difference between a Workers Comp (WC) and a Motor Vehicle Accident (MVA)?
Workers Comp -
It is when an employee gets hurt a work and now needs to seek medical attention. The employer’s insurance will pay for the visits since it happened when the employee was at work.
Motor Vehicle Accident (MVA)-
It is when a person gets into a car accident and now needs to seek medical attention. The car insurance will then pay for the patient visits to help the body part that was injured during the collision.
SLIDE:124
What is the difference from a 1st party and 3rd party claim?
1st Party:
First-party insurance claim is filed with your own auto insurance company for damage due to an accident. Filling a claim with your own insurance company.
3rd Party:
Third-party claim is filed with someone else's auto insurance policy. The other driver's auto insurance company would be responsible for damage.
SLIDE: 151
What is MOVE DOCS? And what do we use it for?
MOVE DOCS-
It's a cloud-based personal injury platform that helps attorneys and healthcare providers reimagine workflows and drive efficiency throughout a patient’s journey to recovery.
- 3rd Party MVA
- Personal Injury Cases
SLIDE: 160
Name TWO 3rd party companies that may call to schedule a worker's comp EMG?
1. Streamline
2.Coast2Coast Diagnostics
SLIDE: 209
TRUE OR FALSE? Tricare East-Prime's member ID could appear as SPONSER ID or ICN
FALSE.
The member ID could appear as Sponsor ID or Benefits number. For Tricare East- Prime ONLY.
SLIDE: 113
Authorization from the adjuster is required for the patient to be treated in what states?
MD, D.C, DE, FL, AL, SC - Auth Required
SLIDE: 134
TRUE OR FALSE? Florida is a at-fault automobile insurance state.
FALSE
Florida is a no-fault automobile insurance state.
It means that the driver cannot use the other party's PIP coverage for their medical expenses. FL residents will have their own PIP and/or medpay to cover accident expenses.
SLIDE:153
In FL & AL, which two providers are not accepting new legal cases?
• Dr. Lesley Walsh is not accepting new MVAs.
• Dr. Rodger Garrett does not see any Legal patients, new or established.
SLIDE: 171
What is One Call and what do they do?
One Call it’s a 3rd party company that has their own call center with reps that dial out to get worker’s comp patients registered and scheduled for EMGs on behalf of the patient.
SLIDE- 205
On the Chesapeake authorization request form, portions of this will be pre-filled out. List the sections of the forms that we should be filling out.
❑ Referral Date
❑ Time
❑ Date
❑ Name of Person Making Request
❑ All fields in the "Injured Worker's Name section
❑ Area of Body (check applicable boxes)
SLIDE: 143
If an adjuster denies treatment for a Mid Atlantic patient, what would be an alternative option moving forward?
The patient can be treated with personal health insurance.
SLIDE: 135
List step by step when a pip is OPEN:
1. We call the adjuster to verify if the claim is 1st party or 3rd party. **Once confirmed 1st party, obtain amount of PIP benefits and update info in insurance notes.
2. When we confirm PIP is available to bill, we override the insurance to ELIGIBLE and add the amount to spend into the insurance and alert box.
3. We call back the patient to schedule, and update the appointment type and notes as NP MVA.
4. If an appointment is scheduled or not scheduled, the "intake" should be assigned to: Npcfollowup
SLIDE: 154
List the doctors who are approved to see MOVE DOCS patients?
Dr. Irwin
Dr. Ruth
Dr. Jari
Dr. M. Hameed (EMG)
Dr. Fadayomi
Dr. Abdeshahian
Dr. Yoon (EMG ONLY)
Dr. Bednarek
Dr. Mychak
Dr. Foo
Dr. John
Dr. McPeek
Dr. Malcolm Moses-Hampton
Dr. Mkandawire (EMG)
Dr. Sanderson
SLIDE: 163
Which slide do we reference to for EMG scheduling notes?
SLIDE: 211
If a caller has a WC case through the DOL that happened outside of the United States. Who do we contact? And what do we have to make sure that we provide?
Bethany Przywieczerski via TEAMS for a quick response
Provide her with the claim number immediately
SLIDE: 145
List the steps we take after completing a Chesapeake Form:
After we fill the Chesapeake form, we must send it:
1.FAX: 410-494-2079
Attention: Precertification department.
• Then we make an alert with date, request sent
for auth (specify if faxed or emailed).
• Follow steps on slide 121-125 to upload a copy
with the document label "Worker’s Comp
authorization request“, assign to npcfollowup.
SLIDE: 143
What is the difference between an open PIP and a closed PIP?
Open-
• We can Schedule
• Please obtain the amount of PIP a patient has left and document in alert and insurance notes. If not able to disclose, get the reps name or reference number.
Closed-
• NEED PIP Exhaustion Letter to use PHI (This confirms there are no funds available to cover medical bills).
• Some patients also have a signed waiver of PIP benefits we can accept this on file to also use PHI for treatment.
SLIDE: 152
When a patient is being referred from MSHC, what are the differences when reaching ot to the adj/atty?
Reaching out to the ADJ/ATTY-
1.If we are unable to reach adjuster/attorney: "Okay to be seen for initial consultation ONLY per Multi-Specialty agreement.
2. If you reached him/her please note once authorization or PIP has been confirmed.
Patients that were referred from MSHC
1. If patients were referred from MSHC and referral is not on file, we must ask in which location they were referred from and call to confirm.
2. To verify insurance info, verify with MSHC representative with referral or patient face sheet.
SLIDE: 166
TRUE OR FALSE? Dr. Lou is credentialled with One Call.
FALSE.
Dr. Lou is NOT credentialled with One Call. We CANNOT schedule with them until they are approve
SLIDE: 210
List Worker’s Comp Specific Fields that should be filled when adding insurance.
Must add:
- Worker’s Comp Claim Number
- Case Injury Date
- Injured Body Part
Adjuster information which includes:
- Last Name
- First Name
- Phone
- Fax
- Repricer Name field can be used for the adjuster's email.
- State in which the first report of injury is filed.
SLIDE: 139
What are the requirements to schedule a SE worker's comp (WC) process?
Provider approval or an open/ unresponsive case to a provider that has been open for over 3 business days
SLIDE:136
TRUE OR FALSE? A letter of protection (LOP), also known as an authorization and assignment (A&A), is a formal contract or agreement that a person will pay back medical costs upon receiving compensation in a personal injury case.
TRUE.
Such arrangements can be helpful to those who were hurt in a car accident but can’t pay their medical bills right away or don’t have insurance.
SLIDE: 156
Who do we send attorney request for worker's compensation or auto accident claims to?
BALANCES
• Bethany Pryzwieczerski
• bprzywieczerski@clearwaypain.com
BILLS OR QUESTIONS
• legal@clearwaypain.com
DEPOSITION REQUESTS
• legal@clearwaypain.com
SLIDE: 172
Once we have the authorization from the 3rd Party Company such as One Call. What would be the steps do we follow to ensure eligibility reflects in Athena?
1. Select "Override payer-returned result" option.
2. In new status we select Eligible
3. In "new reason" select the correct option according where the authorization comes through:
Verbal confirmation
Fax or Email
ELIGIBILITY
Once documentation is received, we can update new reason from Payer Call to Payer Report
SLIDE: 208