Benefits/Eligibility
Scenario:
Caller asked if two providers at Podiatry Center of Idaho were in-network. They also wanted to know if the office was in-network.
CSP advised that the two providers were in-network, but that the facility was out-of-network.
Do you agree with the CSP or what would you do differently?
Fix it:
Check the entity column in SDS. If the entity is a "G," we cannot use that to verify network status of a provider. Network status will be based off of the rendering provider.
Scenario:
Provider called for claim status under the dependent children.
CSP advised that there was no claim on file, but never obtained the dependent's name to verify the information.
What would you do differently?
Fix it:
HIPAA verify all member's that the provider is calling about and make sure you are in the correct account when looking for a claim.
- The CSP advised they continued researching under the Subscriber because that is the name given at the beginning of the call. The CSP assumed that when they asked for the member's name at the beginning of the call, that was also the name of the patient. They missed the "dependent" call-out in the provider's question.
Scenario:
Member calls in asking if they will pay a copay with certain providers once their out of pocket max has been met?
CSP advised co-insurance and prescritions would be covered at 100% but copays would still be payed to the provider.
Do you agree with the CSP's response?
No. Once the out of pocket max has been reached the member will not owe any copays to in network providers.
How many total MTM findings were there in March 2023?
A. 51
B. 47
C. 39
B. 47
True or False:
CSP advised member responsibility of $236.15 for Vitamin D Testing on a claim.
Member confirmed she shows a charge of $232. CSP confirmed that was correct.
Since the CSP spoke the amount correctly and it was the member who said the incorrect amount, this did not result in an MTM error.
False.
- CSP was multi-tasking and just said "correct" when the member stated the amount. The CSP thought the member was just rounding numbers.
Scenario:
Member calls in to verify if prenatal massage is covered.
CSP advises that a prescription/referral from their provider is needed.
Do you agree with the CSP or what would you do differently?
Fix it: Massage does not require a prescription/referral.
- Per Plan benefits and KMT 30176 and 38445, standard Regence administrative guidelines do not require a prescription.
Scenario:
Provider asked if the edit on a procedure code was impacting the denial on the claim.
CSP advised we cannot tell the provider how to bill.
What is the correct action for this scenario?
Fix it:
We can direct providers to what code is causing the issue. It would only be crossing the line if they asked us which code(s) to bill to allow the claim to pay.
Scenario:
Member calls in asking if cataract surgery is a covered benefit. CSP advised that the member does not have vision coverage.
Do you agree with the CSP or what would you advise differently?
No. Cataract surgery falls to medical benefits and would be covered even without vision coverage on the plan.
How many MTM findings were on Alicia's team?
A. 2
B. 3
C. 1
C. 1
True or False:
A CSP provided call reference number 230123456321. The provider repeated it as 23012345632.
The CSP can confirm that the provider has the right call reference number.
False.
Even though the CSP said it correctly the first time, it is an MTM error if they confirm an incorrect call reference number.
- CSP advised they thought they heard the caller say the 1 at the end or could have been distracted by the baby in the background.
Scenario:
Caller asked if x-rays were covered with a 15% coinsurance.
CSP advised yes, after deductible, it would go to 15% coinsurance.
Do you agree with the CSP or what would you do differently?
Fix it: After deductible, the member's responsibility would be 15% coinsurance of the allowed amount.
- Per KMT 32252, it is a requirement to quote "of the allowed amount" when quoting benefits.
Scenario:
A provider called asking about the denial for the claim and wanted to know what information was invalid. The first line had denial code P60 - Claim returned to provider for correction.
CSP advised that there were no edits on the claim and that it does not tell us what those are, and that it does not allow us to tell them.
What would have been the correct action and answer?
Fix it:
KMT 15850 advises CS to view the details within the claim line by line. One line on the claim denied as a CMS OCE edit. We should have advised the provider what line denied and redirected the Regence.com or CMS for further information.
- CSP thought they had the correct answer by reading the denial reason right off the claim.
Scenario:
Member calls in asking about out of network benefits for substance abuse levels of care being PHP and IOP.
CSP quoted after deductible member pays 50% of the allowed amount and any balance of billed charges. Is this a complete benefit quote?
No. CSP did not give a complete benefit quote. They did not mention prior authorization requirements or any possible exclusions.
What was the top trend for MTM errors in March 2023?
A. Claims
B. Benefits
C. Incorrect Info
A. Claims with 19
Benefits: 10
Incorrect Info: 5
True or False:
A caller advised they were calling from Rawlings on behalf of Cigna and wanted to know if a claim was received for DOS 09/17/2020. The ID number populated into SDS, and the caller provided the member's first and last name. The CSP gathered the caller's name and proceeded with the phone call.
Since the CSP got the caller's name, and the member's name, HIPAA was fully verified.
False. Cigna is another insurance company, and the CSP did not obtain the OI's tax ID or national plan code, nor did they confirm if they were the other insurance's business associate.
Scenario:
Member asked for a Claims Itemization for himself and all members in the family for 2022.
CSP emailed multiple EOBs to the member and advised that a claims itemization and an EOB are one in the same.
Do you agree with the CSP or what would you do differently?
Fix it:
An EOB is an alternative to a Claims Itemization, and this needs to be made clear to the member. Per KMT 15663, a writted authorization is required in order to receive a claims itemization for Spouse/Adult Dependents.
Scenario:
Member called about how two claims processed. The out-of-network facility claim denied as P60. The member asked if they owed anything on that claim.
The CSP advised "Not yet, the provider needs to correct the claim."
What is the correct action and answer?
Fix it:
The facility is out-of-network, and while the claim is denied as provider billing error, the claim is denied as member responsibility.
- CSP thought since this was a provider billing error, the member would not be liable. They also thought that since this was Emergency, the member would be protected by the Balance Billing mandate. They did not realize that since the provider was OON, this resulted in the service being "non-covered" and that non-covered services are not protected by the mandate.
Scenario:
Another insurance company calls in and provides member's first name and advises they don't know how to pronounce the last name. The CSP advised that was okay and provided member's last name to the other insurance company.
Has HIPAA been verified or is this a privacy error?
Privacy error. Per privacy tool the other insurance company must provide first and last name of member.
What was the MTM grade percentage for March 2023?
A. 83.4%
B. 82.1%
C. 85.6%
B. 82.1%
True or False:
At the beginning of the call, the CSP asked the caller if they were a third-party biller. The caller advised they were calling from the provider's office and yes, they were from the third-party. CSP moved forward with the call without obtaining third-party billing information.
Because the provider advised they were from the provider's office, HIPAA was fully verified and the CSP was correct.
False. The caller advised they were from the provider's office, and a third-party biller. The CSP should have clarified a second time and gathered the third-party company information before proceeding.
Scenario:
Provider called on a member with a Medical Network of AHN Virginia Mason Franciscan Health Network, asking if provider Jeremiah Ojeaburu was in-network.
CSP channeled the provider and advised they are participating. CSP then gave in-network benefits.
Do you agree with the CSP or what would you do differently?
Fix it: When a member is on a limited network, or a tiered network, review the Providers section on the group page. Participating providers would fall to the out-of-network benefits.
Scenario:
A member called in on a conference call with a provider about reprocessing a claim as COB had previously been updated. The provider advised they originally submitted the claim with the primary values.
CSP contacted RD, and then advised they are not seeing the other insurance information on the claim.
Per the claim image, the primary values are on the claim.
What do you think the CSP missed?
Fix it:
Since the provider states that they did include the primary values on the claim, it is important to review the COB tab and related notes.
- The claim was denied needing MCI information from the member to determine order of benefits.
- CSP advised they assumed the claim was missing the primary carrier's information because typically COB information submitted can be seen on the Claims screen in the Coordination of Benefits section in SDS.
Note: Primary payment information is not pulled into Facets/SDS when the claim has denied for MCI information from the member, because the system won't know what to do with them. It may be necessary to view the image of the claim to view this information.
Scenario:
Subscriber's daughter, not on the policy, calls in requesting new member ID cards for the subscriber.
CSP confirmed address and ordered cards.
Would you have done something differently?
Per KMT, other family members are not listed as approved ID card requestors.
Which state had the highest number of findings in March 2023?
A. Idaho
B. Washington
C. Utah
D. Oregon
C. Utah with 16
Idaho: 12
Washington: 8
Oregon: 11
The provider verified the Group Number and asked for the Group Name to submit a claim. The CSP advised that we cannot release this information.
The Privacy Tool was followed correctly and the CSP was correct.
False. The Privacy Tool only advises to not release the Group Number, the Group Name can be released.