Benefits
When going to a nutricionist visit, is the member eligible to Jace the appointment for 2 or more individuals?
No, the services are not eligible for payment.
“How much time does the member have to submit a claim?”
Par provider INN 12 months
Non - Par Provider OON 24 months
What is the time frame a member has to make their first appeal?
180 days from receipt of original denial
If a provider calls in, what information would you collect prior transferring the call?
Patient's name and ID number
DOB if member ID is not available
Provider's name and tax id number/npi
A member calls upset because they received a bill for a service they thought was covered.
“I understand how frustrating unexpected bills can be. Let me review the claim with you and explain what happened, and I’ll look for any options to help resolve this.”
Can the limitation of medical therapy services be extended by pre-certification?
No, inform the member that they cannot override the benefit limitation.
What services can be considered for a PAR adjustment?”
Pathology, Anesthesiology, Radiology, Emergency
What is the process for requesting assistance from the appeal specialist?
Send route to queue 1117 requesting a call back or status.
When a provider calls to file an appeal: Do we transfer them to the providers line?
It must be handled by member services or premier member services
A member is angry because their prior authorization was denied and they need care urgently.
“I’m sorry this is causing stress. I’ll check the reason for the denial right now and explain your options, including whether an expedited appeal is available.”
What should we include when a member requests a benefit?
Deductible, Coinsurance/Copay, OOP max, Allow amount, confirm if auth is needed and If provider is INN or OON.
If we have already sent a check and the member states they have not received it, what information do we need to verify in order to request a new one?
Check status
Payee name and address correct
Wait up to 30 bd to processs and complete the check cycle.
What types of services can be appealed on an expedited basis?
Inpatient services ,Mental Health, denial of infusion therapy, rehabilitation hospital, skilled nursing facility.
Do not apply to post service claims
If a member calls with a question about a pharmacy, is it necessary to verify the account?
Yes, we need to confirm that the member has RX benefits with us.
A member is frustrated because they were balance billed by an out-of-network provider. what would you say?
“I understand why this would be upsetting. Let me review the claim and see if balance billing protections apply, and I’ll guide you on the next steps.”
What is balance billing?
If a doctor is not in the insurance network, they may charge more than what the plan considers reasonable.
The insurance pays only its allowed amount, and the remaining balance is billed directly to the member.
How long does it take for a claim adjustment to be reviewed?
30-45 BD
How many appeal levels exist and what are the differences in timeframes?
1st Level 180 days from day of denial
2nd level 60 days from receipt
3rd level 15 days from receipt
When we make a transfer to another department, what is important that we provide to the member?
Name and phone number of the place where we are going to transfer and the estimated hold time
A member is upset because they’ve called multiple times and their issue is still not resolved.
“I’m sorry you’ve had to call more than once. I’ll take ownership of this issue and make sure we work toward a resolution today.”
What benefits are offered to the member when they call regarding maternity benefits?
Maternity Nursery Care
Maternity Professional
OBGYN – Outpatient Visit Consultation - Specialist
Ultrasound – Standard Imaging Bloodwork – Pathology
Breast Pump – Under Other services – Women´s Healt Services
Is it possible to request the copay to be waived for an ER visit for rabies vaccine treatment?
Yes, the member is responsible only for the first emergency room visit; the remaining claims are sent for review.
Can you provide some examples of administrative complaints?
Plan benefits, limitations, benefit exclusions, hold/wait time / services provided byt the CSR, discrimination.
“How should calls that were initially intended to be a transfer be documented when the transfer is not completed because the caller decides not to proceed?”
The call should be documented as a cold transfer.
A member is angry because they don’t understand their copay, deductible, or out-of-pocket costs.
“I appreciate you reaching out. I’ll break down your benefits in a simple way so you know exactly what you’re responsible for and why.”