Legacy
If the claim is listed as SOD in appeal tab... will you work this from start to finish or auto assign?
auto assign
When a concierge calls in on behalf of the member. What steps do you follow?
1. Ask them are you the concierge
2. Open a member inquiry
3. Collect contact details for the concierge
4. change the follow up date to 2 days out
5. Select NAO
If the caller calls in for the initial issue to be open. If they state, they don't negotiate and don't want us to handle their claims what will do.
Open an PI
Proceed to collect contact and financials
auto assign claim is non stand on
handle from start to finish if stand on
Do we handle Cigna member calls?
No we refer back to the client, but we still open an issue to document.
For Cigna claims how many days before you can open a Payment status?
45 business days
What client are not Legacy?
Cigna, UHC (EPDP, Student Resources, Rocky Mountain, and Golden Rule), Oxford, Aetna, UMR. *
If the call Is Jill or Jane how do you handle the inquiry?
Open a client inquiry
collect contact and financials and auto assign
For Oxford EPDP and United healthcare EPDP what closure do you use if they dont accept the DIS allowed amount?
Maximum Allowed
What is the timely filing time frame?
365 days
If the claim is closed as Provider Accepted, can you open a Payment status if provider looking for payment?
No because there was no change to the claim. Also provided ACCEPTED THE AMOUNT THAT WAS LISTED.
If the appeal tab say client internal support how do you handle?
Open and issue based on the caller
document caller reason for call
collect contact information
refer them back to client
close claim as internal resolution
For a Health advocate do you collect their contact information?
Yes if they have it but you should be good with just member information
What methodology can we send the EOM for?
You can only send an EOM if pricing is Phys RVU for a HCFA, HCPC median or Outpatient Cost Plus or Inpatient. You cannot send an EOM for CMS %.
If the appeal management say allow settle reverse what issue type to open?
PISR
For Legacy what questions have to be asked before a payment status can be opened?
On what date did you call the insurance company? ii. Do they have the name of the Representative you spoke with? iii. What was discussed?
Are all Legacy Clients 365-day timely filing? How do you determine if it is?
No, in appeal tab
what is Aetna Timely filing time?
timely filing is waived
How long does it take for a provider to receive access to the portal?
up to a week
If the appeal tab states Allow settle stand?
PI(provider Inquiry)
For Legacy if they can't answer the questions listed in the P&P what do you do?
Refer them back to Client
For Legacy which clients have a 5-day tat and have to be auto assigned in 1 business day if they state they will accept?
(Meritain, Scripps, Health Net, Kaiser and UPMC)
Do you handle Aetna Provider calls right now?
No just members
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.
If the claim is Stand on and provider doesn't accept the offer what closure do you use?
Inquiry Resolved
If the successful closure under 45 business day for Cigna, how do you handle?
Refer back to client internal department. Open a Provider Payment Satus Needed and close as Payment status notification can complete. Document call from start to finish.