Scribe Link for “Non Covered Benefit Process for Claims Workflow”


*** This workflow only applies to commercial plan members. If the member has a Medicaid/Medi-cal/Medicare plan, please go down to the Medicaid/Medicare claims section***

 

Apero/Claims Process:


  1. Confirm the claim processed as out of network/non-covered.

    1. Take extra precautions if it is due to a therapist enrollment issue

    2. If you believe this to be part of a therapist enrollment issue, follow this: Process for Working Claims processed or denied for OON Provider

  2. In Apero, create tasks for yourself for all affected claims.

    1. Send voided claims per the situations described in the table below.

  3. Move the status of the invoice to VOID for all affected claims

  4. Make notes in Apero as to why it was denied, and what steps were taken to determine it was a write off. Be detailed.

  5. Attach the “Write off” and appropriate “RFNP - NonCovered Benefit” or “RFNP - Insurance OON” labels to claims in Apero

  6. Mark tasks as “Done”


Scenarios and Statuses for Sending Voided Claims in Apero

  

Scenario/Denial Reason

Send voided claims to insurance?

Invoice Status

Claim Status

Back Bill as Cash? 

OON with Plan

Only when processed towards OON Deductible

Void

Submitted

No

 


Retool/Freshdesk Process:


  1. End insurance coverage and set cash pay coverage for the date of discovery moving forward.

    1. Check to see if a member has a session on the date, you are changing their coverage. You should still change them to cash, but set the member to “do not autobill,” Additionally, set a calendar reminder to waive the session once invoiced, and set the member back to autobill.

  2. Resend current GFE.

  3. Email the member via Freshdesk with one of the canned message options below:

    1. Canned message in FD: “Claims - Claims Processed as Out of Network”

  4. If a copay was charged, waive the copay and refund the member.

    1. If you do not have access to issue a refund, reach out to a manager. 

  5. Make notes in retool on all of the steps above.