Claims

Claims

Search for a Claim

When a members calls to inquire about a claim or questioning why they received a bill, use the procedure below.

Quality Reminders
Fully verify the members account and get any HIPPA release required prior to going over any information. Check members benefits when looking into a claim to make sure it is being processed correctly. Take ownership of the call by calling providers for the member when necessary.

Locate a Claim

1. Locate the members account in HRP.
2. Ask for the DOS for the claim they are inquiring about.
3. Click on the Claims tab.
4. Enter the date of service into the Service Start Date box and click the refresh button.
   1. The search results will appear below.
   2. To add columns to provide more information at a glance, see Column Chooser.
5. Click on the claim to open up the claim detail page.
6. If the claim is present continue to Determine Claim Status.

If a claim is not present...	Then...
and it has been less than 30 days since the DOS	advise the member to allow more time to be received and processed.
and it has been more than 30 days since the DOS	contact the provider to verify they have sent the claim already.
and it has been more than 30 days since the member submitted the claim	request the member resend the member claim form and confirm the address it was sent to.

A new claim will process within 30-45 days from date received depending on the overall claim volume.

Life Cycle of a Claim

Follow the process below to see how the claim is processed once the provider submits the claim.

1. Member receives services.
2. The provider submits the claim by electronic submission or paper.
3. The claim is then processed by the clearing house.
   1. If it is clean claim, it is processed with no assistance from the claims department.
   2. If the claim needs to be adjudicated it will then be processed manually by the claims department.
4. The claim is finalized.
5. Payment is processed and EOP is sent.

There are two methods of how a claim can be submitted and processed:
Electronic Submission

• 80% of claims come in electronically through various clearing houses.
• Claims are loaded by batches 6 days a week from the various clearing houses.

Paper Claims

• Paper Claims are first received by a third party agency who scan the paper claim into their system.
• The claim is then transmitted to PHP through the clearing house and a hard copy image is loaded into OnBase.
• If the claim is a clean claim it can take a minimum of 20 days from the day it was mailed to process.
• If the claim needs adjudication it could take up to 45 days from the day it was mailed to process.
• Without a tracking number there is no way to track if a paper claim was received if it is not loaded in HRP.

Claims Filing Limits

If a member has a claim that is denying due to timely filing limit or is going to send in a member claim form, use the procedure below to determine the timely filing limit.

For inpatient hospital claims, timely filing is determined by the date of discharge to the date received by Presbyterian.

In-Network: ASO, Commercial, PIC Claims Filing Limits:

Claim Type	Filing Limit
New First submission received by Presbyterian	Three months
New claims involving COB First submission received by Presbyterian	Three months from the paid date on the primary carrier's EOB.
Adjustment request Corrected claims, adjustments, late charges, etc.	Within twelve months of the date of service
Adjustment requests involving COB Corrected claims	Three months from the paid date on the primary carrier's EOB. Exception: IHS providers
Indian Health Services	One year from the date of service.

Out-of-Network: ASO, Commercial, PIC Claims Filing Limits:

Claim Type	Filing Limit
New First submission received by Presbyterian	Providers/practitioners are subject to one year. Members are subject to the limit specified for the member reimbursement in the member contract or one year, whichever is less.
New claims involving COB First submission received by Presbyterian	One year from the paid date on the EOB.
Adjustment request Corrected claims, adjustments, late charges, etc.	Within twelve months of the date of service
Adjustment requests involving COB Corrected claims	Twelve months from the paid date on the EOB. Exception: IHS providers
Indian Health Services	One year from the date of service.
Human Services Department	Three years from the date of service.

View Claims Status

When a member calls in to see if we have received and/or processed a claim, use the procedure below.

1. Locate the member's account.
2. Check the member's COB.
   1. For assistance looking up COB on file, see COB Call.
   2. If there is another insurance listed as primary ahead of this plan, see COB Claims .
3. Locate the claim in HRP.
4. Locate the Status box at the top of the claim.
5. Use the table below to determine status of the claim.

If status is...	then...
final	claim has been fully processed, go to Determine Member Responsibility.
denied	go to #Denied Claims.
rejected	go to #Rejected Claims.
needs review	go to #Needs Review.
needs repair	go to #Needs Repair.

Denied Claims

When a claim has been denied in HRP, this means that we have not paid on the claim. Follow the procedure below to determine denial reason.

1. Click on the Summary tab of the denied claim in HRP.
2. Locate the Denials section and use the table below to navigate this table.

Column	Description
Blank	The numbers in blue are links to take you to the specific line item that is being denied for additional information.
Code	The denial code assigned to the line item.
Description	Reason for the claim denial.
Responsibility	Will advise if denial results in member or provider financial responsibility.
Denial Amount	Financial amount of the claim that was denied.

For additional assistance with claim denials go to #Claim Denial Reasons.

Rejected Claims

When a claim has been rejected in HRP, this means the claim was not processed. Follow the procedure below to determine reason for the status.

1. Click on the Audit Log tab on the claim in HRP.
2. Read the notes left by the Claims department by looking under the Reason and Comment columns.

Needs Review

When a claim shows a status of needs review, use the procedure below to determine reason for the status.
Always let the member know that the claim is pending, the information found through the steps below are for internal use and provider use only.

1. Click on the Summary tab.
2. Locate any item with the Exception Type: Review under the Review/Repair Exceptions.
   1. Under the Description column will be the reason for status.
3. Go to the Audit Log tab to see if the Claims department has left additional notes.
4. Advise the caller to allow more time for the claim to fully process.

Needs Repair

This status is used when the system is unable to determine a specific aspect of a claim and needs a claims specialist to review, use the procedure below to determine reason for the status.
Always let the member know that the claim is pending, the information found through the steps below are for internal use and provider use only.

1. Click on the Summary tab.
2. Under the Review/Repair Exceptions locate any item with the Exception Type, "Repair."
   1. Under the Description column will be the reason for status.
3. Go to the Audit Log tab to see if the Claims department has left additional notes.
4. Advise the caller to allow more time for the claim to fully process.

Determine Member Responsibility

When a member is checking to see why they are being billed a specific amount or checking what they may owe for a past service, use the procedure below to determine member responsibility.

Quality Reminders
Fully verify the members account and get any HIPPA release required prior to going over any information. Check members benefits when looking into a claim to make sure it is being processed correctly. Take ownership of the call by calling providers for the member when necessary.

1. Locate the member's account.
2. Check member's COB.
   1. For assistance looking up COB on file, see COB Call.
   2. If there is another insurance listed as primary ahead of this plan, see COB Claims .
3. Locate the claim in HRP.
4. Locate the Status box at the top of the claim.

If the status reads...	then...
Final	continue with the procedure.
Denied	see #Denied Claims.
Rejected	see #Rejected Claims.
Needs Repair, Needs Review or Needs Repricing	Advise the claim is still processing and allow more time.

5. Click on the Summary tab of the claim.
6. Locate the table that begins with Billed Amount.
7. Review the table below for information on the different columns in this section.

Column	Description
Billed Amount	The original amount the provider billed to the insurance.
Allowed Amount	If the provider is INN, this is the contracted rate between the insurance and the provider. If the provider is OON, this is the Reasonable and Customary amount for the service.
HCC Amount	Amount paid by Presbyterian Insurance.
Paid Amount	Amount paid by Presbyterian Insurance.
Member Amount	Total member responsibility for the claim.
Deductible	Amount of member responsibility going to the deductible.
Co-Payment	Amount of member responsibility going to copayments.
Co-Insurance	Amount of member responsibility going to coinsurance.
Member Penalty	Any penalty accrued by the member based on the specific plans rules.
Non-Covered	Amount of any non covered service on the claim.

8. View the payment date at the top of the Summary tab under Financials As of (date).

COB Claim

A COB claim is claim that involves more then one insurance payor. The claim is processed as Primary, Secondary or Tertiary based on members COB order. If the member calls in regarding a COB claim, follow the process below:

Quality Reminders
Fully verify the members account and get any HIPPA release required prior to going over any information. Check members benefits when looking into a claim to make sure it is being processed correctly. Take ownership of the call by calling providers for the member when necessary.

• If the claim processed as primary payor, see Determine Member Responsibility.

1. If the claim processed as secondary/tertiary payor, follow process below:
2. Locate the members account.
   1. Check members COB.
3. For assistance looking up COB on file, see COB Call.
4. Locate the claim in HRP.
5. Click on the COB tab.
6. View the section Other Insurance Payments (Used for adjudication).
7. Under the Member Responsibility column will be the member responsibility left over from the primary insurance.
   1. If nothing appears in the column, click the + next to the line number.
   2. Look at the Member Responsibility column of the newly populated section.
8. Add up all line items member responsibility to see what was left over from the primary insurance.
9. Go to the Summary tab.
10. Locate the table that starts with the Billed Amount column.
    1. Advise the member of their financial responsibility.

• If the claim denied for a COB issue, see Coordination of Benefits Claim Denials process.

Third Party Pricing

Presbyterian uses third party pricing centers that will price the claim based on where the services were rendered and the benefit plan. If a member calls in to verify how the claim was priced, please see below:

Third Party Pricing
#Multiplan Pricing Data iSight Pricing Zelis Pricing

Multiplan Pricing

Presbyterian has a contractual agreement with Mulitplan which is a national PPO network.

• Claims that are priced through Multiplan apply In-Network benefits due to the contract between the provider and PHCS.
• PHCS can only be used when services are rendered out side the State of New Mexico.
• The Multiplan logo is printed on the member ID card with the Statement. "Outside NM Only"
• When a Member visits a Multiplan provider, they should Not be "Balanced Billed"

If a Members calls to verify how the claim was priced in HRP follow the steps below:

1. Access the members account in HRP.
2. Locate the claim.
3. Click on the Lines Tab.
4. Click the arrow to expand line item.
5. Click on the the arrow to expand Line Details.
6. Under Submitted Rendering Practitioner Information.
7. Locate Benefit Network.
   1. Multiplan will appear.

• This means the claim was priced through Multiplan and paid out based on the contract the provider has with Multiplan network.