Scheduler processes appointment request based on patient s insurance coverage.

Transcription

1 Medicare, Blue Cross Blue Shield, In-Network Commercial Insurance (Continued on page 2) Physician/Physician s Office calls to schedule a patient s appointment. Medicaid (Continued on page 3) Scheduler receives appointment request. Scheduler collects patient demographics and insurance information from requesting party. Scheduler processes appointment request based on patient s insurance coverage. Out of Network (Continued on page 4) Other (Continued on page 5) Patient calls to schedule an appointment. Special Circumstances (Continued on page 6) Self-Pay (Please see Appointment Process for New Patients at UMHC (Self Pay) )

2 Medicare, BCBS, In Network ( referral required) Scheduler receives an appointment request for a patient covered by Medicare, BCBS, or another commercial payor accepted by UP. Scheduler makes the appointment based on provider availability. Scheduler verifies patient s eligibility and financial responsibility. Appointment remains as scheduled. eligible and able to meet financial responsibilities? Patient is contacted regarding issue. Patient request is processed as self-pay, out of network, etc. as appropriate. D E Is the issue resolved?

3 Medicaid Patients Scheduler receives an appointment request for primary care visit for a Medicaid patient. Scheduler receives an appointment request for specialty care for a Medicaid patient. Scheduler makes appointment subject to availability. Scheduler verifies eligibility. Is the patient eligible? Patient is instructed to schedule an appointment with their primary care physician or specialist to obtain a referral. Scheduler makes appointment subject to availability. Scheduler verifies eligibility. Was the patient referred? Is the patient eligible? Patient request is processed as self-pay, out of network, etc. as appropriate. Appointment remains as scheduled. D E Appointment remains as scheduled.

4 Out of Network Scheduler receives an appointment request for a patient who is out of network for their plan. Scheduler offers to schedule the appointment for the patient as either selfpay or out-of-network. Patient proceeds with appointment as Out-of-Network. Patient proceeds with appointment as Self Pay. Scheduler informs patient that a $200 deposit and full payment is due prior to a procedure. Scheduler quotes BCBS allowable charge* and instructs patient to pay at time of service or prior to the procedure. Patient is informed that UP will then file their insurance claim and bill the patient for any outstanding amounts due or refund any over payment. Scheduler informs patient that they are receiving a discounted rate and should receive an itemized receipt to file with their insurance. Scheduler makes appointment subject to availability. Scheduler makes appointment subject to availability. * Use the BCBS allowable charge as the discounted rate. Refer to the quoted rate as a discounted rate, not the BCBS rate.

5 Other Cases Scheduler receives an appointment request for a patient with catastrophic insurance coverage only, a benefit plan exclusion, a medical legal case, or a non-contracted plan. A Scheduler informs the patient that they are not eligible for financial counseling because they have other coverage. Have they met their deductible? Does the patient have catastrophic insurance coverage? missing a normally covered benefit? Scheduler quotes BCBS allowable charge. Scheduler informs requestor that the patient or attorney must prepay for all services. Is the appointment related to a medical legal case? Scheduler informs patient that the quoted rate is the discounted rate. Scheduler registers patient as Self Pay. Direct patient to physician administrative staff to schedule an appointment.

6 Is the new self-pay patient referred with a suspected cancer diagnosis or other live, sight, or limb threatening disease? Special Circumstances inancial Counseling collects data needed for initial review. Patient is referred to the CCSC* by potential accepting physician. Was the patient referred to financial counseling? Was all needed information received from the patient? Can service only be obtained at UMHC? Patient is informed they may continue treatment with the same physician (for the current episode of care only) while completing inancial Counseling. under current active treatment? Patient should be referred back to local area physician and not scheduled with UP. below 150% of the poverty level? Patient is informed that they must pay according to their final inancial Counseling status. Patient will be informed by the CCSC that they will receive care free of charge. Scheduler quotes 1 st visit charge to the patient based on Medicare fees and informs patient that this is a discounted rate. Appointment is scheduled subject to provider availability. Scheduler will schedule patient for the next available appointment time. Scheduler instructs patient to pay prior being seen; Patient can contact CBO or inancial Counselor to set up a payment plan. needing to be seen for an emergency situation? Appointment is scheduled for next available appointment time. Scheduler should refer patient to the nearest appropriate ER. Patient should not be scheduled until they have successfully completed the inancial Counseling Process.