SCAN Provider Tools User Training Guide Eligibility & Claims Lookup

Transcription

1 SCAN Provider Tools User Training Guide Eligibility & Claims Lookup Copyright SCAN Health Plan, November, 2011, All rights reserved

2 Table of Contents Introduction 1 Your Account 1 Logging on to the Website 1 Eligibility Verification 3 Search for Members to Verify Eligibility 3 Eligibility Results 5 Prior Eligibility Results for Active Members 6 Prior Eligibility Results for Inactive Members 6 Plan Code Details 6 Using the Hide and Show Controls to Manage the View 8 Printing the List of Benefits in the Plan Code Table 8 Claims Lookup 9 Logging on to the Website 9 Look up a Member s Claims Information 9 Claim Search Results 11 Claim Header Information 12 Patient Information 12 Provider Information 12 Claim Detail Information 13 Printing 14 Claims Provider Service Line 14 Appeal a Claim 14 Claim Appeals 15 i

3 Introduction This manual shows you how to use the Eligibility module to verity member eligibility on the Online Provider Tools website This manual also shows you how to use the Claims Lookup module to examine a member s claim information Your Account Before you can access the Online Provider Tools, your administrator must set up your account and grant you access Your administrator will: Assign you a user ID Assign you a password Provide you with the URL address for the Online Provider Tools website Once you have your user ID and password, you can log in to Eligibility Lookup and Claims Lookup on the Online Provider Tools website Logging on to the Website Use the URL address provided by your administrator to go directly to the website If you do not remember the URL, log on to Online Provider Tools as follows: 1 Open your browser and enter wwwscanhealthplancom in the address field 2 Click California in the upper right corner of the screen under PROVIDER TOOLS 3 On the Provider Tools screen, do one of the following: For Eligibility: Click Eligibility Lookup in the list of options under ELIGIBILITY VERIFICATION in the blue panel on the left side of the screen For Claims Lookup: Click Claims under QUICK LINKS in the navigation panel at the left side of the screen, and then click the Claims Status Look Up button in the Claims Information table The Existing User Login screen is displayed as shown in Figure 1 on the next page 4 Enter your user ID and password and click the Submit button The following disclaimer message is displayed: SCAN Health Plan ("SCAN") has created a "Provider Tools" function on its website for purposes of allowing registered and authorized Providers to view the status and handling of their claims By checking the "I Agree" box below, every time that you access information in Provider Tools, you agree that you are the individual that contacted SCAN and became a registered and authorized user that has been granted access to Provider Tools This access cannot be transferred or shared among Provider staff, or otherwise used, shared, viewed by any third party, or copied in any manner without the express written consent of SCAN Every individual using this function must register with SCAN independently SCAN is not liable for any misuse or damages arising from this function's use 5 Review the message and click I Agree to continue I Agree Member Eligibility & Claim Lookups Training Guide 1

4 Welcome to the SCAN Health Plan Online Provider Tools If you are experiencing difficulties with the Login page, please contact SCAN at If you have forgotten your password, click here User ID Password Submit To set up a new log-in and password please call SCAN at Figure 1 Existing User Login screen Copyright 2004 SCAN Health Plan, Inc All Rights Reserved When you click I Agree, you confirm that you are a registered and authorized user for SCAN s provider tools The Welcome screen is displayed as shown in Figure 2 Online Provider Tools Eligibility Claims Lookup Claims Billing Information Change Password Claim Appeals Claims Download AZ Tools User Guide CA Tools User Guide Logout At SCAN, our mission is to continue to find innovative ways to enhance seniors' ability to manage their health and to continue to control where and how they live We understand that our provider relationships are critical to accomplishing our mission and our Provider Portal and Tools are intended to improve these relationships by making it easier to work with SCAN and reducing the cost of doing business with us Copyright 2004 SCAN Health Plan, Inc All Rights Reserved Figure 2 Welcome screen Member Eligibility & Claim Lookups Training Guide 2

5 Eligibility Verification This module allows you to retrieve eligibility and benefits information for up to ten members on a single search Search for Members to Verify Eligibility 1 Click Eligibility in the navigation panel, and click close in the popup window to clear the search options message The Eligibility screen is displayed as shown in Figure 3 Figure 3 Eligibility search screen The Eligibility screen allows you search for members by combining five kinds of user information in one of three combination options: Option 1: Member ID AND First Name AND Last Name AND DOB Option 2: Member ID OR Medicaid ID AND Last Name AND DOB Option 3: Member ID OR Medicaid ID AND First Name AND DOB See some examples on the next page Member Eligibility & Claim Lookups Training Guide 3

6 Examples, Option 1 (Member ID AND First Name AND Last Name AND DOB): To use the member ID, first and last names, and DOB to retrieve the eligibility information for John Smith, fill in the search fields as shown below and click the Search button Alternatively, you can fill in the first and last names using only the first initials, like this: Example, Option 2 (Member ID OR Medicaid ID AND Last Name AND DOB): To use the Medicaid ID, first and last names, and DOB to retrieve the eligibility information for John Smith, fill in the search fields as shown below and click the Search button: You can also use the Client Index Number (CIN) or the AHCCCS ID in the Medicaid ID field Example, Option 3 (Member ID OR Medicaid ID AND First Name AND DOB): To use the Medicaid ID, first name, and DOB to retrieve the eligibility information for John Smith, fill in the search fields as shown below and click the Search button: You can also use the Client Index Number (CIN) or the AHCCCS ID in the Medicaid ID field 2 Examine the search results as described on the next page Member Eligibility & Claim Lookups Training Guide 4

7 Eligibility Results When you click the Search button, the current eligibility results and the prior eligibility results are shown in a set of tables for each member you searched for, as shown in Figure 4: Eligibility Updated As Of: 9/27/2011 3:42:36 PM Printer Friendly SMITH, JOHN - Member ID: Current Eligibility General Information Group# ACTIVE click to close Effective Dates PCP Effective 08/01/2010 Hospital Name ST JOSEPH HOSPITAL MG/IPA Effective 08/01/2010 IPA# / MG# 0990 Plan Code Effective 01/01/2011 IPA / MG Name GOLDEN POND Birth 03/19/1936 PCP # PCP Name WELBY, MARCUS Plan Code Details Plan Code HHI Click Here For Details Copays PCP: $000 ER: $5000 Specialist: $500 Hospital: $5000 Prior Eligibility 08/01/2010 to 12/31/2010 click to close Figure 4 Current Eligibility Results Notes: 1 In this example, only one member was searched for, so only the current and prior eligibility results for that member are shown 2 Click Printer Friendly to print a copy of the results, if desired 3 Current Eligibility and click to close are toggle controls: Click them to hide the results table, and click them again to show the results table, as you wish 4 Click the underlined plan code to display a list of detailed benefits for the plan 5 If you searched for two or more members (up to ten) the results for all members searched and found are shown For each member: The member s status, ACTIVE or INACTIVE, is indicated at the far right in the first row of the results table For each member: General information, effective dates, the member s DOB, copay information, and the plan code are shown in the eligibility results For each member: One or more Prior Eligibility tables of information may be shown depending on how long the member has been enrolled 6 Current and prior eligibility information is available for a rolling twenty-seven months Member Eligibility & Claim Lookups Training Guide 5

8 Prior Eligibility Results for Active Members Prior Eligibility and click to close are toggle controls: Click them to hide the results table, and click them again to show the results table, as you wish Prior Eligibility Results for Inactive Members For inactive members, the effective end dates are shown for the prior eligibility period, and the presentation is slightly different, as shown in Figure 5 JONES, SALLEY - Member ID: Prior Eligibility INACTIVE click to close Eligibility for period 09/01/2010 to 12/31/2010 General Information Group# Effective Dates PCP Effective 06/01/2008 Hospital Name ST JOSEPH HOSPITAL PCP End 12/31/2010 IPA# / MG# 0990 IPA / MG Name ON GOLDEN POND PCP # PCP Name GAZZARA, BEN MG/IPA Effective 06/01/2008 MG/IPA End 12/31/2010 Plan Code Effective 06/01/2008 Plan Code End 12/31/2010 Birth 09/05/1944 Plan Code Details Plan Code 106 Click Here For Details Copays PCP $1000 ER $5000 Specialist $1000 Hospital $10000 Figure 5 Prior Eligibility Results Plan Code Details When you click the Plan Code link, a collapsed view of the plan code details is displayed as shown here: Benefits for Plan Code HCI Print HCI ( Open ) Click here to close this window Click the show control ( ) to expand the view and display the benefits for the plan code, as shown in Figure 6 on the next page Member Eligibility & Claim Lookups Training Guide 6

9 HCI ( Open ) Inpatient Care Service Type Code Service Amount Limit 47 Hospital $5000 per day (1-8) $000 per day (9-90) Outpatient Care Service Type Code Service Amount Limit 98 Physician PCP Visit $ Specialist Visit $500 Outpt Med Servs & Supplies Service Type Code Service Amount Limit DM DME 0%-20% $0 for items $0-$99 20% for items $100 plus 75 Prosthetic Devices 0%-20% $0 for items $0-$99 Preventative Services Service Type Code Service Amount Limit CL Bone Mass Measurement $000 CL Colorectal Screenings $000 Additional Benefits Service Type Code Service Amount Limit ILP RN Renal Dialysis $000 1 Nutrition Therapy $ Part B Covered Drugs 20% Service Type Code Service Amount Limit 42 Benefit Llimit Personal Care Coordination 20% for items $100 plus Figure 6 Plan Code details Click here to close this window Member Eligibility & Claim Lookups Training Guide 7

10 Six categories of benefits are described in the Plan Code table: Inpatient Care Outpatient Care Outpatient Medical Services and Supplies (abbreviated) Preventative Services Additional Benefits ILP Using the Hide and Show Controls to Manage the View The list of benefits is quite long, so you must scroll down to see the benefits at the bottom To avoid scrolling up and down through the list, you can hide each category to obtain an overview and then look at them individually Click the hide control ( ) for each category to collapse the list of benefits to look like this: Benefits for Plan Code HCI Print HCI ( Open ) Inpatient Care Outpatient Care Outpt Med Servs & Supplies Preventative Services Additional Benefits ILP Then click the control on a category to see the list of benefits for that category Printing the List of Benefits in the Plan Code Table You can click the printer icon to print the list of benefits, if desired Member Eligibility & Claim Lookups Training Guide 8

11 Claims Lookup In this module, you look up the claim information for one member at a time This section also provides instructions for submitting a form to appeal a claim Logging on to the Website If you are already logged on to Online Provider Tools, log out of the Eligibility module and click Claims Lookup Otherwise, log on to Online Provider Tools as described on page 1 Look up a Member s Claims Information 1 Click Claims Lookup in the navigation panel The Existing User Login screen is displayed as shown in Figure 1 on page 2 2 Key in your User ID and password and click the Submit button The Claims Lookup search screen is displayed as shown in Figure 7 Eligibility Online Provider Tools Claims Lookup Claims Billing Information Change Password Claim Appeals Claims Download AZ Tools User Guide To find information about a claim, please enter the Claim ID, SCAN Member ID number (11 digits, dashes are optional), Medicaid ID number, or the check number * At least one search criteria must be provided Member ID Claim ID Medicaid ID Check Number CA Tools User Guide Logout Figure 7 Claims Lookup search screen Copyright 2004 SCAN Health Plan, Inc All Rights Reserved Member Eligibility & Claim Lookups Training Guide 9

12 Claims Lookup allows you to search for claims information for one member To search for a member s claim, key in one or more of the following in the corresponding fields and click the Submit button: Enter the member's SCAN Member ID number (11 digits) Enter the Claim ID Enter the Medicaid ID Enter the Check Number Note Claims in SCAN s pre-adjudication system not yet written to MC400 (SCAN s Health Information System) will not have a Claim ID or Check Number Consequently, these claims can be found only by searching for them using member data such as the Member ID or Medicaid ID for the dually enrolled members A summary of the claim information for the member is displayed as shown in Figure 8 Online Provider Tools Eligibility Claims Lookup Claims Billing Information To find information about a claim, please enter the Claim ID, SCAN Member ID number (11 digits, dashes are optional), Medicaid ID number, or the check number * At least one search criteria must be provided Change Password Claim ID Member ID Member Provider ID Provider Date of Service Claim Appeals Claims Download AZ Tools User Guide SMITH,JOHN ABC MEDICAL GROUP SMITH,JOHN ABC MEDICAL GROUP < Previous 1 Next > 6/10/2010 1/07/2010 CA Tools User Guide Logout Copyright 2004 SCAN Health Plan, Inc All Rights Reserved Figure 8 Claims Lookup information summary Member Eligibility & Claim Lookups Training Guide 10

13 Click the claim ID to display the search results for the claim, as shown in Figure 9 Claim Search Results The Claim Search Results screen presents the claim information in four sections: Claim Header Information Patient Information Provider Information Claim details in a table with thirteen columns of information The information shown on this page reflects current information as of the close of the previous business day Claim Header Information Patient Information Claim Number Member ID DCN Number Medicaid ID Claim Status Date 11/2/2011 Member Name SMITH,JOHN D ANSI Claim Status Category FO ANSI Claim Status 1 Status Finalized Provider Information Billing ID Billing NPI Billing Name ABC MEDICAL GROUP IPA Code 1234 From Service Date Thru Service Date REV/HCPC Code Procedure Modifier Procedure Qty Billed Amount Amount Paid Service Provider NPI ANSI Category Code ANSI Status Code Status Check# RA/Check Date** 2/22/2010 2/22/ $1040 $ F3F 16 Forwarded /11/2010 2/22/2010 2/22/ $10725 $ F3F 16 Forwarded /11/2010 2/22/2010 2/22/ $9867 $ F3F 16 Forwarded /11/2010 2/22/2010 2/22/ $ $ F3F 16 Forwarded /11/2010 *For further information move cursor over ANSI Status Code **RA Date will be displayed if no check was issued RA/Check Date will not appear if claim is Pending/In-Process ANSI Detail Claim Status Codes/Descriptions: 16 Claim/encounter has been forwarded to entity Click here for a printer friendly view Click here for the Claims Provider Service Line Click here to appeal this claim Figure 9 Claim Search Results Member Eligibility & Claim Lookups Training Guide 11

14 Claim Header Information The Claim Header Information section provides the following information: Claim Number: MC400 Form Number DCN Number Claim Status Date: Today s date ANSI Claim Status Category: This is a HIPPA-required, industry standard code which provides the high-level status of the claim ANSI Claim Status Code: This is another HIPPA-required, industry standard code which provides a more specific status for the claim Status: This is the SCAN proprietary claim status description The following status types can be displayed at the claim header level: o o o Finalized: If none of the detail lines associated with a claim are Pended/In-Process, and all of the lines are Paid or Denied, this is the status which will appear at the header level Pending/In-Process: If at least one of the detail lines on a claim are Pending/In-Process, the claim header status will be Pending/In-Process Rejected: If all of the detail lines on a claim have a Rejected status, the claim header status will be Rejected o Forwarded: If all of the detail lines on a claim have a Forwarded status, the claim header status will be Forwarded ** Claims with a Rejected or Forwarded status will not have a Form Number since they have been rejected or forwarded directly out of SCAN s pre-adjudication system and were not written to MC400 Patient Information The Patient Information section provides the following information: Member ID: SCAN Member Number Medicaid ID: Medicaid ID for the state Medicaid program under which the member is also enrolled Member Name Provider Information Provider Information section provides the following the following information: Billing ID: MC400 Provider Number for Billing Provider NPI: Billing Provider s National Provider Identifier Billing Name IPA Code Member Eligibility & Claim Lookups Training Guide 12

15 Claim Detail Information The claim detail Information table provides the following information: From Service Date: MC400 Provider Number for Billing Provider Thru Service Date: Billing Provider s National Provider Identifier Rev/HCPC Code: The Revenue or HCPC code submitted for a given claim line o If an HCPC code or a CPT code was submitted with a Revenue code, the HCPC code or the CPT code will be displayed in lieu of the Revenue code o If only a Revenue code was submitted for a given claim line, only the Revenue code will be displayed Procedure Modifier: The modifier displayed in this field represents the Primary modifier only Procedure Qty: Number of units submitted Billed Amount: Total billed amount/charges submitted for a specific claim line Amount Paid: Amount paid for a specific claim line Service Provider NPI: This represents the NPI for the rendering provider For an institutional or professional claim for which there is no separate rendering provider, the Billing Provider s NPI will be displayed in the Service Provider NPI field ANSI Category Code: This is a HIPPA-required, industry standard code which provides the high-level status of the claim ANSI Status Code: This is another HIPPA-required, industry standard code which provides a more specific status for the claim Descriptions of the ANSI status codes are displayed directly below the table of claim details, as shown here: ANSI Detail Claim Status Codes/Descriptions: 16 Claim/encounter has been forwarded to entity The MC400 Not-Covered and Adjustment Reason codes and descriptions associated with a specific claim line will appear in a pop-up window when you mouse over the row in the table Status: This is the SCAN proprietary claim status description The following status types can be displayed at the claim detail level: o Reversal o Pending/In-Process o Encounter o Forwarded o Paid o Denied Member Eligibility & Claim Lookups Training Guide 13

16 Check Number: A check number will only be displayed if a check was issued for the claim detail line For example, if a claim is Pending/In-Process no check number will appear in this field RA/Check Date: A date will only appear in this field if a check was issued for the claim detail line If no check was issued, then the date the RA (Remittance Advice) was issued will be displayed in this field If a claim is Pending/In-Process, this field should be blank Printing Click Click here for a printer friendly view to print a hardcopy of the results Claims Provider Service Line Click Click here for the Claims Provider Service Line to display the phone number for the service line Appeal a Claim Click Click here to appeal this claim to go to the Claim Appeals screen Member Eligibility & Claim Lookups Training Guide 14

17 Claim Appeals To appeal a claim, follow the instructions listed on the Claim Appeals screen, as shown below All required fields must be completed prior to submitting the form A Claims Representative will process the submitted appeal(s) Updates will be sent via Member Eligibility & Claim Lookups Training Guide 15

18 Member Eligibility & Claim Lookups Training Guide 16