Process Handling 1
For United healthcare do we have 365 days timely filing that we follow for providers calls?
YES
What client's do we use Member Balance Bill Issue type for?
UHC, UHC EPDP, UMR, Oxford, Oxford EPDP, Golden Rule Inc., Rocky Mountain, or Student Resources
If provider want to accept the offer for Aetna Provider calls and they sign the Letter of Tem.... What closure do you use?
DIS Provider Accepted Recommendation
How long does it take for a provider to receive access to the portal?
Up to a week
if claim is closed as Successful Negotiation, can you reopen for review again.
No
For Aetna calls is the 365 timely filing day rule waived for all inquiries?
No its not
If the member calls in and state that they haven't received the Email with the URL link to upload their bill. What steps would you do?
1st step check to see if the email is correct
2nd if it is checking the portal tab to see if it is still active
3rd ask them to check their spam and trash folder
4th if they still can't find it resend the link in the action drop down and select Request BB
Make sure to advise them what email the URL link will be coming from
For Aetna provider if they don't accept offer what closure will you use
Inquiry Resolve
The provider is asking for something in writing when we refer them back to the client. What is your response?
Unfortunately we do not have anything to provide in writing. Please contact the insurance and let them know you have spoken with me at Data iSight, and that you would like to discuss any additional appeal options.
For UHC and Affiliates when a provider calls in for payment what are the steps to follow if it's over 45 business days for the first call?
Refer the provider to call Provider Service, the phone number found on back of the member ID card and follow the prompts.
2. Open a Provider Inquiry.
3. Advise the provider: Please contact Member or Provider service at the number on the back of the member’s ID card. We have completed our handling and provided the recommended outcome to (client name). The claim(s) is currently pending with (client name) for resolution.
4.Document from start to finish
5. Close as Internal Resolution
For NJ surprise bill if they don't accept the offer what appeal options will you give the provider. What closure do you use?
EmailNJ_outofNetwork@uhc.com
Certified mail via the address on the back on member id card
Web from https://www.uhcprovider.com
Inquiry resolve
Do we use Member balance bill Request issue type for Aetna Member calls?
No we use Member Inquiry
For UHC EPDP and Oxford EPDP what closure will use if they dont accept the offer
Max allowable paid
If the provider states they do not want a callback, or refusing the discount or do not want to Negotiate, what is your response?
“I understand you are frustrated, but I am escalating for a callback to one of our specialist who can provide you with more details around the pricing and assist you with your questions.”
If provider call in for a payment that hasn't been received on a claim for UHC and affiliates that was closed as Successful for second time how to handle claim from start to finish?
Open PRN- Provider Payment Status Needed issue (type allows for specified tracking for this situation / criteria)
2. Confirm with the provider / caller their name and phone number.
3. Inquire/confirm their contact with the client’s Provider Service Department.
4. Request the following information and document the response in issue notes: • Phone number on the back of the member ID card? • Who did they speak to? • What date and time did they call the client? • Were they given a reference number? o If so, what was the number?
5. Refer the provider / caller back to Provider Services # on back of the member ID card and request an escalation.
6. Close as Payment Status Notification (Can Complete)
What claims do we work as stand on Intake end from start to finish?
Oxford EPDP, UHC EPDP and Aetna and some Cigna
Will the action request bb automatically send or do we have to send it manually?
Automatically send
How long can you hold stand on claims in your queues that you work from start to finish?
10 business days
The provider is saying he/she was paid less than the DIS Allowed amount that they accepted and is inquiring about the remaining payment. What is your response?
When the allowed amount is accepted this does not mean additional payments will be made to the provider. The provider will need to direct questions about payments to client
If a claim is closed as Max Allowed for UHC and affiliates how to handle from tart to finish?
1. Open Provider or Member Inquiry
2. If the member is calling on a claim that has the HBP indicator, and the prior Provider Inquiry was closed Max Allowed Paid, open a Member Inquiry and Auto assign.
3.Was contact made with the provider? Did we speak to someone? No - previous contact made to the provider 1. Open new issue 3 2. Auto Assign
4.Yes - Contact made and we spoke to a representative. 1. Open an issue. 2. Document call in the claim issue in Toolbox 3. Close as Internal Resolution using the Approved Verbiage below.
5.If a provider is calling back to accept a previously declined max offer, advise only the previously disclosed allowed amount will be offered. No counteroffers will be accepted. 1. Open a new issue 2. Include in notes the o Provider called back to accept previous max offer 3. Auto Assign
if claim is closed for a Member inquiry and the member calls in only to check status. How would you work it from start to finish.
1.Provide the member with the detail outcome
2. and open a MI and close
3. Document from start to finish
4. if claim is eligible to reopen then reopen
5. closs internal resolution
If a client calls in with the member on the line or back line, would you open a Member BB request issue type?
No, open Member Inquiry Issue Type
If you get a counteroffer would you close the claim as provider accepted or inquiry resolve for Aetna?
inquiry resolve.
If a provider calls and would like to know how much we allow for a service before they actually see the patient. What is your response?
?
We are not able to provide any information upfront before receiving the claim from the Insurance. Each claim is handled on a claim by claims basis, and all claims are not routed to us.
For Aetna Member calls if the claim is passed 365 days were do you assign he Intial claim to?
CVQ