Provider Claims Billing

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

Agenda



Overview: Managing Your Revenue Cycle

Overview: Managing Your Revenue Cycle

 Eligibility & collect co-pay  Referral/Auth/NIA  Make a referral  Policies 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 Electronic Claim Remittance Advice  Auto post remittance Reduce Outstanding Account Receivables  Claim Status  Eligibility  Referral/Auth/NIA  Policies

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

Guide to Eligibility Verification

 EDI-Direct, HPHConnect, NEHEN, and NEHENNet  Provider_callcenter@hphc.org  Phone: (800) 708-4414 Medicare Enhance, and Medicare Supplement Choice Plus &

Options (offered jointly with

Guide to Eligibility Verification

and Harvard Pilgrim Health Care)

 NEHEN (UnitedHealthcare)

 www.UnitedHealthcareOnline.com  Phone: (800) 708-4414

Student

Insurance Plan  Phone: (800) 977-4698 (StudentResources)

HPHC Plans administered by Health Plans, Inc.

 EDI Direct, NEHEN, and NEHENNet  www.healthplansinc.com

 customerservice@healthplansinc.com

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

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

Guide to Referral, Notification and

Authorization Submission

 HPHConnect, NEHEN, and NEHENNet

 Fax: (800) 232-0816  Phone: (800) 708-4414 Senior Plans: Medicare Enhance Medicare Supplement

Do not require referral, notification, or authorization

Choice Plus & Options (offered jointly with

UnitedHealthcare)

 HPHConnect, NEHEN, and NEHENNet

Guide to Referral, Notification and

Authorization Submission

and Harvard Pilgrim Health Care)

 www.UnitedHealthcareOnline.com  Phone: (800) 708-4414

Student Insurance Plan

Student Insurance Plan does not require pre-admission notification. Confirm referral

requirements with member.

HPHC Plans administered by Health Plans, Inc.

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

Payment Policies Online

Alphabetical

from A-Z with date of last update

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 699183 Quincy, MA 02269-9183 Medicare Enhance Medicare Supplement  Submit to Medicare.

 Medicare will coordinate to automatically cross-walk those claims and submit them electronically to

Guide to Claims Submission

Plan Electronic Mail

Choice Plus & Options (offered jointly with

UnitedHealthcare)  EDI-Direct  HPHConnect  NEHEN/NEHENNet  Vendor – payer #04271

Harvard Pilgrim Health Care PO Box 699183

Quincy, MA 02269-9183

Choice & Choice Plus “Passport Connect”

(from UnitedHealthcare and Harvard Pilgrim Health Care)

Vendor – payer #87726 Check back of

Member’s ID card.

Student Insurance Plan

Emdeon – payer #74227 Harvard Pilgrim Health Care _{StudentResources} PO Box 809025

Guide to Claims Submission

Plan Electronic Mail

HPHC Plans administered by Health Plans, Inc.

 EDI-Direct  HPHConnect  NEHEN/NEHENNet  Vendor–payer #04271  Emdeon – payer #44273

Health Plans, Inc. PO Box 5199

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

Guide to Checking Claims Status

 EDI-Direct, HPHConnect, NEHEN, and NEHENNet

 Provider_callcenter@hphc.org  Phone: (800) 708-4414 Medicare Enhance, and Medicare Supplement Choice Plus &

Options (offered jointly with

Guide to Checking Claims Status

and Harvard Pilgrim Health Care)

 www.UnitedHealthcareOnline.com  Phone: (800) 708-4414

Student

Insurance Plan  Phone: (800) 977-4698 (StudentResources) HPHC Plans

administered by Health Plans, Inc.

 https://www.healthplansinc.com

 customerservice@healthplansinc.com

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