Thinking Question's
Does the 365-day timely filing period apply to United Healthcare & Oxford when the provider is calling?
Yes
(UHC & Oxford Timely filing is waived for Member & Client only)
The Member Balance Bill Request Issue type is only used for which clients?
UHC, UHC EPDP, UMR, Oxford, Oxford EPDP, Golden Rule Inc., Rocky Mountain, or Student Resources
How long can a Stand on claim stay in your que?
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 because our handling is complete on our end
Is the 365-day timely filing rule waived for all Aetna calls?
yes
Aetna Timely filing is waived for all calls.
If there is an already opened Member BB request Issue type and the member is calling in stating, they haven't received the email with the with the link, what would you do?
You would ask them to check their spam to see if it went there.
If it didn't go to spam, then just resend the link to them again. Add an action Request BB to the already opened issue type
For Aetna provider calls only if they don't accept offer what closure will you use?
inquiry resolve
provider is stating that they do not want they claims sent to us. Can we stop it on our end? Or what can we say to them?
No
Advise the caller you do apologize but the claims are sent to us by the client/insurance. You will need to contact the client and speak with their internal department to discuss having your claims not sent to us for pricing.
What status should be in your queues c, b, z?
c only
Open a member Inquiry
Auto assign the issue
Provide the member script listed in the NJ surprise bill P&P.
If you get a call from the patient advocate on behalf of the member which issue type, do you open?
Member Inquiry or Member BB Request
Member BB Request
For UHC EPDP and Oxford EPDP what closure will use if the provider doesn't accept the offer?
Max allowed
If the provider states they do not want a callback, or refusing the discount or do not want to Negotiate, we respond:
“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 there is no savings- lost savings on the claim, can you reopen the claim up again for review?
No, we can't we will refer caller to the client for any additional questions?
What info would you provide if the caller asks to place you on hold?
Advise the caller that you can hold for up to 3 minutes. If longer than 3 minutes, you may disconnect the call. Before hanging up, attempt to make a general statement that you are hanging up due to no response.
Document the reason call was disconnected.
This is for the UHC & affiliates only
If the client is calling in on behalf of the member with them on the line, will you open a member bb request? Or will you open a MI?
Member inquiry (MI)
If the provider accepts the DIS Allowed amount, will they get additional payment?
NO
If the provider calls in and state that they login is not working on the portal, what can you do or say?
apologize to the provider/ show empathy
advise them you can send an email to Discustomerservice@dataisight.com and a ticket will be opened through our support team?
What is the time frame that the TIN has to be in for us to still consider it as Municipal Ambulance?
12 months
Will you use closure types DIS Successful Negotiation or Unsuccessful Negotiation when closing an issue?
No
Only the appeals team (Claims specialist) will use those closure types.
If the member has paid upfront for services & the claim is for UHC & affiliates. What issue type would you use & what document will the member need to upload?
Open issue as Member Balance Bill Request & they will need to upload a copy of the statement/receipt.
How long can you hold a Meritain claim in your queues if the provider states that they are willing to accept the offer, but you get no response from the provider?
1 business day and then you have to auto assign
If a provider calls and would like to know how much we allow for a service before they actually
See the patient.
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 UHC member inquiry for a Municipal ambulance claim how would you close it?
BB May occur