Provider Claims Billing

Transcription

1 Provider Claims Billing

2 Objective At the end of this session, you should be able to recognize the importance of using Harvard Pilgrim s online tools and resources to manage the revenue cycle: Multiple options for eligibility verification, referral/notification/ authorization submission, and claim status inquiry Comprehensive Provider Manual containing detailed information about Referral, Notification and Authorization; Payment Policies; Billing and Reimbursement; and Appeals Process 2

3 Agenda Overview: Managing Your Revenue Cycle Claims Billing 3

4 Overview: Managing Your Revenue Cycle Reduce Outstanding Account Receivables Claim Status Eligibility Referral/Auth/NIA Policies Provider Claim Reports Scheduling & Patient Visit Eligibility & collect co-pay Referral/Auth/NIA Make a referral Policies Electronic Claim Remittance Advice Auto post remittance Claim Submission Eligibility Referral/Auth/NIA Submit Claim Policies Work In-Process or Rejected Claims Response Report/ File Claim Status Eligibility Referral/Auth/NIA Policies 4

5 Claims Billing

6 Member Eligibility View and copy front and back of member ID card for: Plan Name ID number Cost sharing information Provider service and claim submission information Verify member eligibility When the appointment is made On the date of service Prior to billing 6

7 Guide to Eligibility Verification Plan Options Harvard Pilgrim HMO POS PPO Medicare Enhance, and Medicare Supplement EDI-Direct, HPHConnect, NEHEN, and NEHENNet Phone: (800) Choice Plus & Options (offered jointly with UnitedHealthcare) 7

8 Guide to Eligibility Verification Plan Choice & Choice Plus Passport Connect (from UnitedHealthcare and Harvard Pilgrim Health Care) Student Insurance Plan HPHC Plans administered by Health Plans, Inc. Options NEHEN (UnitedHealthcare) Phone: (800) Phone: (800) (StudentResources) EDI Direct, NEHEN, and NEHENNet Fax: (508) Phone: (800)

9 Referral Referral required for specialty care services for HMO members and for POS members in-network benefits Failure to bill with the referring provider name and NPI on the CMS 1500 claim form will result in a claim denials with no patient liability 9

10 Notification/Authorization Prior authorization and/or notification requirements may differ by plan for Inpatient admissions Outpatient therapy services Select procedures, services and items Notification/authorization requirements apply for third party liability (i.e., MVA, worker s compensation, etc.) and secondary claims also Failure to obtain appropriate authorization/ notification approval may result in claim denials with no patient liability 10

11 Referral/Notification/Authorization Policies Online 11

12 Guide to Referral, Notification and Authorization Submission Plan Harvard Pilgrim HMO POS PPO Senior Plans: Medicare Enhance Medicare Supplement Choice Plus & Options (offered jointly with UnitedHealthcare) Options HPHConnect, NEHEN, and NEHENNet Fax: (800) Phone: (800) Do not require referral, notification, or authorization HPHConnect, NEHEN, and NEHENNet Fax: (800) Phone: (800)

13 Guide to Referral, Notification and Authorization Submission Plan Choice & Choice Plus Passport Connect (from UnitedHealthcare and Harvard Pilgrim Health Care) Options Phone: (800) Student Insurance Plan Student Insurance Plan does not require pre-admission notification. Confirm referral requirements with member. HPHC Plans administered by Health Plans, Inc. Fax: (508) Phone: (866)

14 Filing Limit For initial claim submissions, 90 days from the date of service For coordination of benefits claims, within 90 days of primary insurer s payment or denial Copy of primary carrier s EOP required Failure to submit a claim within the filing limit will result in a claim denial with no patient liability 14

15 Payment Policies Online Alphabetical from A-Z with date of last update Billing requirements may be outlined in payment policy 15

16 Billing and Reimbursement Requirements Online 16

17 Guide to Claims Submission Plan Electronic Mail Harvard Pilgrim HMO POS PPO EDI-Direct HPHConnect NEHEN/NEHENNet Vendor payer #04271 Harvard Pilgrim Health Care PO Box Quincy, MA Medicare Enhance Medicare Supplement Submit to Medicare. Medicare will coordinate to automatically cross-walk those claims and submit them electronically to Harvard Pilgrim. 17

18 Guide to Claims Submission Plan Electronic Mail Choice Plus & Options (offered jointly with UnitedHealthcare) Choice & Choice Plus Passport Connect (from UnitedHealthcare and Harvard Pilgrim Health Care) Student Insurance Plan EDI-Direct HPHConnect NEHEN/NEHENNet Vendor payer #04271 Vendor payer #87726 Emdeon payer #74227 Harvard Pilgrim Health Care PO Box Quincy, MA Check back of Member s ID card. Harvard Pilgrim Health Care StudentResources PO Box Dallas, TX

19 Guide to Claims Submission Plan Electronic Mail HPHC Plans administered by Health Plans, Inc. EDI-Direct HPHConnect NEHEN/NEHENNet Vendor payer #04271 Health Plans, Inc. PO Box 5199 Westborough, MA Emdeon payer #

20 Checking Claims Status Use Harvard Pilgrim s electronic transactions to know when your claim has pended or denied and to quickly resolve it HPHConnect EDI-Direct NEHEN/ NEHENNet Send multiple claim inquiries at one time receive a reply within 30 minutes 20

21 Guide to Checking Claims Status Plan Options Harvard Pilgrim HMO POS PPO Medicare Enhance, and Medicare Supplement EDI-Direct, HPHConnect, NEHEN, and NEHENNet Phone: (800) Choice Plus & Options (offered jointly with UnitedHealthcare) 21

22 Guide to Checking Claims Status Plan Choice & Choice Plus Passport Connect (from UnitedHealthcare and Harvard Pilgrim Health Care) Student Insurance Plan HPHC Plans administered by Health Plans, Inc. Options Phone: (800) Phone: (800) (StudentResources) Phone: (800) (Health Plans, Inc.) 22

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25 Summary

26 Claims Billing Resources Harvard Pilgrim provides a variety of tools and resources to assist providers with timely claims billing Multiple options available for Eligibility verification Referral/notification/authorization submission Claim status inquiry Online Provider Manual containing Referral/notification/authorization policies Payment policies Billing & reimbursement requirements 26

27 Questions?

28 Thank You