# data[].attributes.body
Step 4: Quote benefits Remember to quote ALL accumulators that apply! (DED, OOP/COINS MAX, TOOP, HRA, visit limits, caps, etc.)
See Quoting Disclaimers below for helpful tips.Related article: How to use auto-documentation when quoting benefits

# data[].attributes.body
Step 3: Verify Coverage / Auth Requirements
For Self-funded plans, verify auth requirements at a group level.Some groups have different auth requirements / exclusions.
Enter CPT code into your Knowledge Global SearchIf there is a related medical policy or article, check for authorization requirements and coverage limitsThe list of medical policies can be found here: Using CPT codes and Medical policies to verify coverageIf no results are found, search by name of procedureIf there is a related medical policy or article, check for authorization requirements and coverage limitsThe list of medical policies can be found here: Using CPT codes and Medical policies to verify coverageIf no Medical policy or article results for CPT or name of procedureCode is covered by Priority Health as long as medically necessaryRemember! IP services ALWAYS require authorization

# data[].attributes.body
Step 2: Verify Provider Participation (using the Who and Where from above)

Check to see if all physicians /facilities / locations are participating (in-network) or OON (out-of-network)

# data[].attributes.body
Ask the 5 Ws (WHO, WHAT, WHEN, WHERE and WHY).
Who is the physician that will be performing the service / procedure?NOTE: This will be needed for step 2 to verify provider participation What service / procedure is being done having done? (Procedure Codes)Obtain a procedure code.NOTE: This will be needed for step 3 to verify coverage When is the service / procedure being done?Verify if plan has a DED CarryoverSee article: Deductible including carryover and credit requests Where is the service / procedure being performed at? Will it be Inpatient or outpatient?NOTE: This will be needed for step 2 to verify provider participation Why is the service / procedure being done? (DX codes)Obtain a diagnosis code.NOTE: This will be needed for step 3 to verify coverage

# data[].attributes.body
How can someone sign up for insurance with PH?

Online

Marketplace

Agent

Retention

Short Term Education

Narrow Network Education

Telehealth Education

Member Portal Education

[9:36 AM] Lewis, Angelica

We only take enrollment calls for My Priority Plans

# data[].attributes.body
Where can a member locate a copy of a preexisting letter > ONBASE

# data[].attributes.body
Who eligible for Pre PPAC Plan?
Eligible Dependents of existing mbrs

Who can terminate a policy?
Subscriber and Agent

How long does Special Enrollment last?
60 days

When route term request to mypriority?

When would you route over a termination request?

1. Member moving out of state

2. member medicare eligible

3. mbr is going to medicaid,
4. or member is moving to group insurance

HICS Case like a Appeal- through Market Place

MyPriority HICS vs. Appeal

Wrong Term Date

3-5 business days > enrollment mypriority

How to check status of HICS Case- call a SME

Can a mbr cancel Delta Dental? Cannot cancel until open enrollment

What should we click on if a mbr wont pull up/ Click on mbr not on file

Market Place # 800 318 2596

5 Life Events Qualify

birth of new born
death
divorce
marriage
loss of coverage

ways to sign up for health coverage priority health individual policy

1. Market Place
2. Online
3. Agent
4. Retention/Sales

What Education giving mbrs?
Narrow Network
Short Term
TeleHealth
PHMP

What product do we take enrollment calls for?
My Priority Plans

Where can I find a copy of Pre-existing Letter?
Onbase

Benjaman calling to cancel Sarah ex wife off the plan sub cat?
DIV- divorce

KA Mypriority Termination Codes

We can never give quotes to Agents
they go to Priority Quotes  and we never shadow

Short term cannot be extended

Difference between Cost Share Reduction-Ded & Opp
73 87 94

Advanced Premium Tax Credit- Subsidy-lowers Premiums
KA: MyPriority product training

10 Essential Health Benefits

look in progression training/enrollment billing

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10 Essential Health Benefits
1.    Ambulatory Patient Services (Outpatient)
2.    Emergency Services
3.    IP Hospitalization
4.    Maternity and Newborn care (Prenatal and Postnatal Care)
5.    Mental health and Substance Abuse treatment
6.    Prescription Drugs
7.    Rehabilitative and Habilitative Services
8.    Lab Services
9.    Preventative Services
10.    Pediatric Services

# data[].attributes.body
Open Enrollment period 11/1/2022 thru 1/15/2023 to have a policy for 1/1/2023 must sign up before 12/15/2022

if you sign up from 12/16/2022 thru 1/15/2023 your policy will start as of 2/1/2023

# data[].attributes.body
apply.

We cover preventive services based on the latest medical research and the national guidelines set by the U.S. Preventive Services Taskforce, Centers for Disease Control and Prevention and Health Resources and Services Administration.

# data[].attributes.body
deductible applies to all services except:
-preventative care
-first 4 INN physician visits

# data[].attributes.body
Balance billing is when a provider bills a beneficiary or member for an amount above and beyond the Medicare allowable reimbursement rate.

# data[].attributes.body
HealthEquity

# data[].attributes.headline
what are the 2 kind of grandfathered plans

# data[].attributes.subject
what are the 2 kind of grandfathered plans

# data[].attributes.body
TRANS 2025 or lower
2025 ext plan

what accounts do we do benefits and claims only
MP only

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When receiving calls for a member enrolled on a short-term policy, the following three (3) points should ALWAYS be provided to the caller:

1. Preventive care is not a covered benefit.

2. Pre-existing conditions are an (exclusion) to the policy

3. Prescription (Rx) is a discount only program.

# data[].attributes.body
US preventive services task force(USPSTF)
centers for disease control (CDC)
health resources and services administration

# data[].attributes.body
HOW LONG CAN A MBR HAVE A SHORT TERM POLICY

WHAT IS AN ACCIDENT RIDER? bodly harm

# data[].attributes.body
especial enrollment period

WHAT OPEN UP AN SEP -

Moving to a different ZIP code or county

A student moving to or from the place they attend school

A seasonal worker moving to or from the place they both live and work

Moving to or from a shelter or other transitional housing

# data[].attributes.body
when 12/15/2013 is the last time a pre paca plan can be purchased

# data[].attributes.body
con cor mamo gram birth control

# data[].attributes.headline
10 Essential Health Benefits ( ACA Plans)

# data[].attributes.subject
10 Essential Health Benefits ( ACA Plans)

# data[].attributes.body
Ambulatory Patient Services (Outpatient)
Emergency Services
IP Hospitalization
maternity and newborn care (Prenatal & Postnatal Care)
Mental Health and substance abuse treatment
Prescription Drugs
Rehabilitative and Habilitive Services
Lab Services
Preventive Services
Pediatric Services

# data[].attributes.body
MyPriority Members: the member is entitled to a 60 day Special Enrollment Period when they gain a new dependent. See MyPriority Newborn Process

# data[].attributes.body
Mbr adv he submitted application through marketplace last night, Advised mbr I do not see an active acct on file. Can take up to 30 days for PH to receive anything from the marketplace. Gave # 1800 318 2596 to Follow up if he wants to.

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"I would have to get you transferred over to a different department, can I place you on a brief hold?"

-Thank you,

-You click on the PAUSE BUTTON

-then click on the conference button (2 grey people)

-you will dial the extension and get in contact with another CSR.

-Reach out to another CSR "Hello my name is Darryltrese I am calling from the individual dept, I have ____ ____ on the other line. They are fully verified, here is their call back #." "Did their contract #/ Information come across your screen?"

CSR States: "Okay you can bring them over"

Me: Okay thank you, I will go ahead and introduce her to you.

Then you would have to click on the conference button where the circle is

and now you are merging the call it is now a 3 way call.

# data[].attributes.body
63891 FF HMO/ POS MBR

# data[].attributes.body
PHMP Education is a separate inquiry

MyPriority Fully Funded HMO Individual- PRIORI003/ Need to find hospital affiliation

Medicaid: PRIORI001 Need to find 2 hospital affiliations

Employer Narrow Network- need to find PCP:YES

MyPriority Narrow Network Plans- need to find PCP: YES

KA: Provider Network IDS; how do  I know if a provider is participating

KA:  PCP Change process & Criteria

# data[].attributes.body
Make sure to put a "91" in front of the number

when doing a call back

# data[].attributes.body
Claims | Cigna pricing issues - issues around incorrect processingFront end rejections (that are not scanning errors on paper claims)General inquiries about claimsWhen ID cards have been lost/stolen and member wants a new ID number. (once CLAIMS has investigated/research they will send to enrollment to process new ID card request)Medicare CrossoverSingle Case AgreementsYou must include code I39 in any inquiry notes/comments which are being routed to this queue

Claims Adjustment | Claims that need to get adjusted (at an 02 status) accumulator questions.

When we need to recover $ paid on claim (take backs) or we owe additional $(i.e. gathering pre-existing information from provider, send inquiry here)You must include code I39 in any inquiry notes/comments which are being routed to this queue (for all reasons except scanning
error rejections)Scanning errors / misread paper claims - You must include code I43 in
any inquiry notes / comments. See article: Front
end rejections for more details and documentation standards.

Claims-Resolved Issues | Resolved issuesClaims w/out paymentOON claim that needs Data iSight pricingCOB denial where member states they have NO other insurancePCP was updated / changed and claims need reprocessingYou must include code I39 in any inquiry notes/comments which are being routed to this queue

COB | Claims issues associated with COB to determine primacy, reporting
or updating COB information (e.g. BCBSM, Aetna, Cigna, etc.)See article: COB:
explaining primacy (dependent children, divorce, retiree, Champus/Tricare)
You must include code I39 in any inquiry notes/comments which
are being routed to this queue

Status Codes and Explanations
01 – Accepted; Awaiting BatchProcessing complete, waiting for batch / check run | Claims batch on the Sunday following claim status date.

If claim has been at 01 for long time route to Claims Audit queue
02 – Accepted; Batch CompleteProcessing complete, Payment or Denial processed |
11 – Pended; Awaiting BatchInternal Pend – Claim needs to be worked by the Claims Dept | These claims are still being worked and information about the claim should not be provided.

It either needs more work, is missing information, or it needs a nudge.Look at the
date received, as well as the last time that it was worked.

If there is not a recent entry made in the Claim status or Notes link as to what is occurring, route the inquiry to Claims to give current status.

See Decoding pended claim status codes
15 – Pended with ErrorsDeficient Claim – Claim needs to be worked by the Claims Dept.
91 – Adjusted; ProcessedOriginal claim adjusted – Replacement claim is same except the last
number. | Why was claim adjusted?Check Claim notes link in the Claim details tab.

Claim examiners will not enter a note if they have a descriptive explanation code explaining the adjustment reason.
99 – ClosedClaim must be resubmitted by provider - Typically due to an incorrect
code or additional information is required. | Why is the claim closed?Check Claim notes link in the Claims details tab.

A letter is sent to the provider informing them why the claim needs to be rebilledThis letter can be found in OnBase under Facet Letters - Claims
Letters (related article: Finding
letters in OnBase)

# data[].attributes.body
When are are sending an inquiry back to the claims dept:

- We have to include "i39" & include claim #, Claim DOS, and reason for review

# data[].attributes.body
Multi claim inquiry—DOS range and Provider name if single provider.

Example Single DOS, multiple providers: 8/13/2019 Multiple providers
Example Multiple DOS, single provider:  11/13/2017-12/15/2017  SAENZ, ADELITA
Example Multiple DOS, Multiple providers where claims might be related (TPL or COB investigation): 7/1/19-8/13-19 Multi Providers

Claims Not on file or Front-End Rejections —

Member CSRs: DOS, Provider Name, Billed amount -- Please include all details that are obtained

# data[].attributes.body
PH NEVER bills the mbr for a visit, its the provider thats billing them we just let the mbrs benefits apply towards the claim so we can process it

PH will not mail out EOBS if mbr has a zero dollar liability for a claim or has any flat copayment due.

EOBS are sent out to the mbrs AND the providers as well

# data[].attributes.body
Category: Benefits
Sub Category: Coverage Details
Summary Line: 1-2 word description
Ex.  Antibody Testing

# data[].attributes.body
Deductible Preferred/In Network > This means In network individual Deductible / on the same line you will find the in network family Deductible

# data[].attributes.body
Deductible Integrated Medical/RX- this simply means in network deductible

If coinsurance is less than 100% we need to quote the maximums tab

Individual TROOP Dollar Medical/RX In Network/Preferred - Individual In Network Max Out of Pocket

# data[].attributes.body
Deductible- EMBEDDED VS. AGGREGATE

Embedded deductible-

family plan of 2 or more we have to quote individual deductible & family deductible.

See key words "But not to exceed"

-We only have one individual on the plan? > only quote individual Deductible.

Aggregate

-mbr has a family plan of 2 or more

only family deductible should be quoted-family deductible only applies

There are specific key sentences: " If you have more than one individual on the contract, only family deductible applies"

If you have only one individual on the contract "Only individual deductible applies" -still remains aggregate deductible.

# data[].attributes.body
Jan 1st is when the accumulators all go down to 0.00

# data[].attributes.body
Deductible- amount mbr is required to pay before priority health pays for covered services

Copay- flat dollar copayment that is due at the time of service

Coinsurance- when deductible has been fulfilled-this is when coinsurance begins- example (PH pays 80%/ mbr pays 20%) ("Shared Cost")

Max Out of Pocket- Whatever the mbr pays towards coinsurance will go towards their max out of pocket -

If mbr meets their deductible or max out of pocket, PH will cover the mbr at 100% for all covered services

Premium - "Monthly Subscription" Monthly Premium paid once a month

# data[].attributes.body
Mbrs cannot use their HSA card to pay for their medical premium

# data[].attributes.body
PPO- in and out of network benefits

HMO- in network benefits only except urgent care, emergency room, ambulance services

# data[].attributes.body
Rx BIN: 003858
Rx PCN: A4
Rx Group #: PHEXCHG

# data[].attributes.headline
Type: (This field is required. This information is for tracking use only.)

# data[].attributes.subject
Type: (This field is required. This information is for tracking use only.)

# data[].attributes.body
N = New | Member has a new contract
D = Duplicate
| Member already has ID Card, requesting additional set (i.e. extra card for dependent childThe issue with using the "D" type has been resolved (updated 2.17.2021)
R = Replacement  | Member misplaces ID Cards, requests replacement
C = Change | Change to member/contract that changes what is being printed on ID Cards (i.e. name change, adding dependent, etc…)

# data[].attributes.body
-We can complete PCP changes
-ID cards
-We CANNOT complete address changes we can only document this information
-Refer mbr to their case worker or can update address in myhealthbutton app
Download App

# data[].attributes.body
MyPriority PPO:
-We can do everything for these mbrs
-Address changes have to be routed over to enrollment-mypriority

MyPriority HMO (Direct PH mbr)
-We can do everything for these mbrs address changes have to be routed to enrollment my priority

MyPriority HMO (FFM)

we can only document demographic changes we have to refer mbrs to the Marketplace # 1800 318 2596
-We cant adv why a subsidy has increased/decreased based on income information from the marketplace

-other than these things we can do everything for these mbrs

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-PCP Change
-ID Card
-Change Address by going in "Profile Section"
-We can verify provider participation
-Send out PCP/Specialist Directories (EXCEPT) > Vision & Dental
-We can update the phone # in the Profile Section

more_vertical

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-we can document and route demographic changes to Enrollment-route group

# data[].attributes.body
-PCP Change
- ID card
- We can only document address change in specialized inquiry we have to refer them to their employer.
-We can verify provider participation
-Send out PCP/Specialist Directories (EXCEPT) > Vision & Dental

# data[].attributes.body
we do NOTHING for self funded mbrs
transfer  #: 63761

# data[].attributes.body
we do NOTHING for self funded mbrs
Warm Transfer to: #63792

# data[].attributes.body
we can do everything for them

# data[].attributes.body
we can only document demographic(Demographic Changes;

-DOB Change

-Email Change

-Name Change

-SS# change)

changes we cant actually complete it. they have to contact MP or call 1800 318 2596

We can do everything else

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Benefits will be excluded under this Policy for each Illness or Injury or condition for which, during the five year period prior to your effective date, medical advice, diagnosis, care or treatment was recommended by or received from a Health Professional. For purposes of this limitation, “treatment” includes the use of prescription drugs. Genetic information is not treated as a Pre-Existing Condition in the absence of a diagnosis of a condition related to the genetic information.

This plan is not intended to be of a permanent nature and pre-existing conditions are not covered.

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•Mbr can only stay within their Network.

•HMO networks can include Narrow Network

•If mbr goes out of their Network the visit will not be covered.

•The only Out of Network Benefits that the mbr has is (Urgent Care, Ambulance Services, & Emergency Room Services)

•Keep in mind…since mbr is going to an OON provider reasonable and customary rates/charges may apply.

•What does this mean? = Medicare + 20%, Rates in that area/based on average cost.

# data[].attributes.body
•Mbr has In and Out of Network Benefits

•**We should refer mbr to see an INN provider instead bc it will be a lower cost to them**

•*Remember In network providers have contracted rates w/ PH*

•Out of Network providers do not have contracted rates w/ PH.

•PCP is not required to have on File

•Deductible Applies to all services except preventive care & first 4 office visits/urgent care

# data[].attributes.body
plans are always direct PH plans

PRE-PPACA plans- deductible is going to apply to everything except preventive care- and first 4 urgent care/office visits

# data[].attributes.body
PRIORITY HEALTH # 1800 528 8762

# data[].attributes.body
MYPRIORITY HMO- 1. select business category as HMO/ 2, Find PRIORI003./ 3. Look for hospital affliation that says PCP: YES

My Priority NARROW NETWORK- Select medical business category as HMO/ find the provider ID: then make sure it says PCP: YES

# data[].attributes.body
PPO- preferred provider organization-no PCP required

HMO- health maintenance organization- PCP required to be on file

# data[].attributes.body
Pathology, Hospitalist, Anesthesiology, Radiology & Emergency physicians

# data[].attributes.body
1. Network Participation- yes

2. Answer question is it covered? CPT Codes/ Diagnostic Codes: yes

3. How is it covered (What Benefit do we quote?)

4. Deductible –(EMBEDDED OR AGGREGATE?)- EMBEDDED

5. Copay- no

6. Coinsurance: 70%

7. Maximum: (Do we Quote?)- yes

8.. Out-of-Pocket Limits:

9. Troop:

10. Where am I with coverage = Accumulators

11. Frequency & limitations = Prior Auth, Visit limits etc- prior auth -

# data[].attributes.body
Start of call
"Thank you for calling Priority health my name is -----, can I get your first and last name"
"Alright, -------, can I get a good call back number?"
"Thank you for that, can I get a Member ID or Contract Number?"
"Alright, what can I help you with?"

If transfering:
"Hi this is ----- from individual side I have ----- on the line I'm not trained to handle this call"

End of call:
"Alright, is there anything else I can assist you with today?"
"Okay, there is a survey at the end of this call if there is nothing else, have yourself a wonderful day"

# data[].attributes.body
Please send detailed claim report to

CARL W REAMS

8681 MARSH RD

CLAY MI 48001

adv 5-7 business days

# data[].attributes.body
Mbr called in for cost estimate for brain ct (no contrast) - adv mbr the following
mbr adv going to Integrated Care Campus - East Beltline 2750 E BELTLINE AVE NE GRAND RAPIDS, MI 49525
Market price- $332
Price at this location- $266
Deductible you'll pay- $266
You'll pay an estimated- $266*
adv mbr can get cpt code from provider
adv-Prices shown are estimates, and not all procedures listed are covered by all our plans. This information is solely for use by our plan members to estimate their health care costs. Priority Health is not responsible if this tool shows you inaccurate costs.

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How To

COB: Explaining primacy (dependent children, divorce, retiree, Champus/Tricare)

PHARE applies to PPO plans only

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Under the new legislation, out-of-network PARE providers are now required to give you disclosure ahead of providing non-emergency services. This documentation must include:

1. A statement that your insurer (Priority Health) may not cover all services;

2. A “good-faith” estimate for services to be provided;

3. A statement that you may request care from an in-network provider instead;

If your good faith estimate from the scheduling provider includes services from an out-of-network provider (such as a pathologist, anesthesiologist, radiologist or emergency room physician) and you wish to request a switch to an in-network provider please contact your scheduling provider. Ask them to help you find an in-network provider for all services you require.

4. An acknowledgement of understanding that you or your representative must sign ahead of the procedure acknowledging that you have been provided with a disclosure form and cost estimate at least 14 days in advance of the service.

If you sign the form, you agree that you may be balance-billed by the out-of-network PARE provider.

# data[].attributes.body
PHARE stands for Pathology, Hospitalist, Anesthesiology, Radiology & Emergency physicians

# data[].attributes.body
Once plan has been verified, please proceed using the following script at your discretion.

“I see you are enrolled in a __________ plan.  I would like to take a moment to provide you with a few key points regarding your plan:”

1. “All covered services must be obtained with providers within your participating network in order to receive “in network” benefits.” Do you have any questions on what that means to you or do you need assistance in selecting providers within your network?

2. “Service received outside of your network is not a covered benefit.”  Here is what that means to you… (provide an example of coverage and how that would impact the member)

3. “You are currently assigned to Dr._________ as your PCP.  Is this correct?”

(If yes, please confirm if the current PCP is within the member’s network.  If no, when you change the PCP make sure the provider is “in network”)

# data[].attributes.body
COB: Explaining primacy (dependent children, divorce, retiree, Champus/Tricare)

# data[].attributes.body
This is the documentation standards we would use if Mbr has no other insurance

# data[].attributes.body
For Family planning, HIV/AIDS or STD information, SUBSTANCE ABUSE INFORMATION, MENTAL HEALTH INFORMATION. we are to NEVER share diagnosis or coding language with anyone except the member

# data[].attributes.body
INQUIRY #, REEASON FOR THE CALL, & What you have already looked at as a resource

# data[].attributes.body
This is a replacement claim and all lines have been reprocessed under a new claim number. Check claim notes for the new claim number.

# data[].attributes.headline
Make sure to include i39 whenever you are sending a claims inquiry over to claims dept, or claims adjustment

# data[].attributes.subject
Make sure to include i39 whenever you are sending a claims inquiry over to claims dept, or claims adjustment

# data[].attributes.body
When you are sending over a claim to be reviewed you have to include

1. The CLAIM # you want to be reviewed

2. i39

3. Reason for the review

4. Date of Service

# data[].attributes.body
01 – Accepted; Awaiting BatchProcessing complete, waiting for batch / check run | Claims batch on the Sunday following claim status date.
If claim has been at 01 for long time route to Claims Audit queue
02 – Accepted; Batch CompleteProcessing complete, Payment or Denial processed |
11 – Pended; Awaiting BatchInternal Pend – Claim needs to be worked by the Claims Dept | These claims are still being worked and information about the claim should not be provided.

It either needs more work, is missing information, or it needs a nudge.Look at the date received, as well as the last time that it was worked.
If there is not a recent entry made in the Claim status or Notes link as to what is occurring, route the inquiry to Claims to give current status.
See Decoding pended claim status codes
15 – Pended with ErrorsDeficient Claim – Claim needs to be worked by the Claims Dept.
91 – Adjusted; ProcessedOriginal claim adjusted – Replacement claim is same except the last number. | Why was claim adjusted?Check Claim notes link in the Claim details tab.
Claim examiners will not enter a note if they have a descriptive explanation code explaining the adjustment reason.
99 – ClosedClaim must be resubmitted by provider - Typically due to an incorrect code or additional information is required. | Why is the claim closed?Check Claim notes link in the Claims details tab.
A letter is sent to the provider informing them why the claim needs to be rebilledThis letter can be found in OnBase under Facet Letters - Claims Letters (related article: Finding letters in OnBase)

# data[].attributes.body
Closed Claim- means the claim must be resubmitted by the provider- typically due to an incorrect code or additional information is required

We can look at the reason for closed claim- under Claim notes

# data[].attributes.body
PENDED: AWAITING BATCH- WE CANNOT PROVIDE ANY INFORMATION ABOUT THAT CLAIM

# data[].attributes.body
Advised mbr will take  estimated 60 business days for the whole process. Advised mbr will route it over to TPL investigation dept, estimated 15 business days for inquiry to be reviewed.

# data[].attributes.body
TPL representative makes first contact to the member via phone explaining the process and next steps.

1. A voicemail is left if there is no answer.

2. If member not reached within 24/48 hrs. a no-reach or denial letter will go out.

The letters are located in OnBase. (see article: Finding letters in OnBase)

Retrieval > Facets Letters> Facets Letters-Member letter > Use Date of note to pull correct letter

1. If member does not respond within 2 weeks, the investigation is closed until the member calls or returns the letter

What you should do:

1.  If a member calls stating they received a letter from TPL, do the following:

1. Check member notes to identify if the member received a call from TPL (See question and answer below)

2. If the member received a call, warm transfer to TPL phone queue (833.415.9061 or 616.464.8452)

3. Only members identified as receiving a call should be transferred. All other callers follow the current process.

# data[].attributes.body
R&C - Reasonable & Customary: The average reasonable cost for a particular service which is applied in the absence of a contract with a particular provider (Medicare Rate + 20%)

# data[].attributes.body
Single Claim inquiry— DOS, Provider name, Billed amount

Multi claim inquiry—DOS range and Provider name if single provider.

Example Single DOS, multiple providers: 8/13/2019 Multiple providers
Example Multiple DOS, single provider:  11/13/2017-12/15/2017  SAENZ, ADELITA
Example Multiple DOS, Multiple providers where claims might be related (TPL or COB investigation): 7/1/19-8/13-19 Multi Providers

Claims Not on file or Front-End Rejections —

Member CSRs: DOS, Provider Name, Billed amount -- Please include all details that are obtained

PROVIDER CSRs Must include all 3: DOS, Provider Name, Billed amount

Summary For Multiple FE Rej. Claims — FRONT END REJECTION: Multiple Claims

Inquiry Notes:

For each claim: DCN#, DOS, Provider Name, Charged amount, Front end rejection reason

I43 OnBase claim shows correct information, please process

# data[].attributes.body
in This scenario Mbr had a mammogram

on 12/29/2021 PROVIDER NAME: WILLIAM BEAUMONT HOSPITAL

had a 2nd mammogram on

1/12/2022- PROVIDER:

KONCZALSKI, MARIE | BILLED AMOUNT: $264.00

Claims documentation standards and auto-documentation (Shared Knowledge: Comm, Prov, Sr Mrkts)

Example Multiple DOS, single provider: 12/29/2021-1/12/2022, WILLIAM BEAUMONT HOSPITAL

Always provide claim numbers, date of service and other details that may be helpful.

You must include the following language, Code I39 (aka EOB adj code), in any task notes which are being routed to these queues:

# data[].attributes.body
After that last bonus question Snider, Kendra can you send them on a 10 minute wiggle please

OU2 - Info req for possible pre-x

# data[].attributes.body
Claims tips and routing (Shared Knowledge)

What does the status Pended: Awaiting batch mean?

# data[].attributes.body
J35 - Info req from member for diag | Claim will be reconsidered if accident detail info is received from member

Refer provider to bill member until the requested information is received by Priority Health.  - THIRD PARTY LIABILITY

# data[].attributes.attachment_caption
ANYTIME YOU ARE GOING TO QUOTE HOSPITAL SERVICES BENEFIT YOU HAVE TO QUOTE PHYSICIAN SERVICES

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Hospital Outpatient Care and Hospital Observation Care Services

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Hospital Outpatient Care and Hospital Observation Care Services

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(Including ambulatory surgery center facility charges)
--$1,000.00 Copayment for outpatient surgery services, then 80% Coverage of the charge balance
--80% Coverage for all other Hospital Outpatient Care and Hospital Observation Care
--Some services may require Prior Authorization, including certain radiology examinations
--Deductible applies.

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TROOP, MOOP ,OOP SAME THING = MAX OUT OF POCKET

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Step 3:  Once plan has been verified, please proceed using the following script at your discretion.

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Step 3:  Once plan has been verified, please proceed using the following script at your discretion.

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“I see you are enrolled in a __________ plan.  I would like to take a moment to provide you with a few key points regarding your plan:”

1. “All covered services must be obtained with providers within your participating network in order to receive “in network” benefits.” Do you have any questions on what that means to you or do you need assistance in selecting providers within your network?

2. “Service received outside of your network is not a covered benefit.”  Here is what that means to you… (provide an example of coverage and how that would impact the member)

3. “You are currently assigned to Dr._________ as your PCP.  Is this correct?”

(If yes, please confirm if the current PCP is within the member’s network.  If no, when you change the PCP make sure the provider is “in network”).

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Create inquiry

1. open onbase-go to import

2. Fill in DOCUMENT TYPE GROUP: CUSTOMER SERVICE

3. DOCUMENT TYPE- CS-Customer Inquiries

4. fill in member ID # section with the contract #

5. Fill in inquiry #

Click On Browse to UPLOAD the document

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EMBEDDED DEDUCTIBLE (2 OR MORE ON THE PLAN):

-WE QUOTE individual deductible & family deductible

EMBEDDED DEDUCTIBLE ( JUST ONE INDIVIDUAL ON THE PLAN)

-We are only quoting the individual deductible-

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Susan and John have a family health plan that covers them and their three children. Each family member has a $500 individual deductible, and they have a $1,000 family deductible. Susan meets her $500 deductible after giving birth to their youngest child in February. The son, Tommy, breaks his leg and also meets his $500 individual deductible in March, which means the family deductible of $1,000 has now been met. Later in the year, when John needs carpal tunnel surgery, he only owes a copayment because the family deductible was already met

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Deductible applies to all services except:

•Preventive Care

•First 4 INN physician visits (including physicians and Urgent care visits)

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Accident or Accidental: An event that occurs after the effective date of this Policy and meets all the following requirements:

•Causes harm to the physical structure of the body;

•Results from an external agent or trauma;

•Is the direct cause of a loss, independent of any disease, bodily infirmity or any other cause;

•Is definite as to time and place; and

•Happens involuntarily or entails unforeseen consequences if it is the result of an intentional act.

•An Accident does not include harm resulting from an Illness.

•Injury: Accidental bodily damage or loss.

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In network providers have contracted rates with priority health, they are only allowed to bill a certain amount to the members insurance. EX: PROVIDER BILLS 500.00 FOR A DERMATOLOGIST VISIT, BUT ACCORDING TO THEIR CONTRACTED RATE< THEY CAN ONLY BILL 250.00 FOR THE VISIT, that 250.00 will go towards members deductible

providers who do not have contracted rates are OUT OF NETWORK PROVIDERS- if dr brown is out of network, they can bill as much as they want and member will be responsible for the cost.

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The member or their authorized representative may submit an appeal regarding and decision Priority Health has made.Once the case is received at Priority Health, the appeals department will pull information regarding the case and submit to a committee for review.The process takes an average of 15-35 days.The member will be notified via mail on the determination that was made on the case

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The process takes an average of 15-35 days.

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SHORT TERM PLANS- ALL 3 PLAN DESIGNS HAVE 80% COINSURANCE FOR IN NETWORK BENEFITS/60% COINSURANCE FOR OUT OF NETWORK BENEFITS.