***Please note: This situation only applies when a Member’s plan is in network with NOCD, but the therapist they were assigned is out of network with their plan.***
Apero/Claims Process:
Confirm the claim processed as the therapist is OON with the member’s plan
Take extra precautions if it is due to a therapist enrollment issue
If you believe this to be part of a therapist enrollment issue, follow this: Process for Working Claims processed or denied for OON Provider
In Apero, create tasks for yourself for all affected claims.
Send voided claims per the situations described in the table below.
Move the status of the invoice to VOID for all affected claims
Make notes in Apero as to why it was denied, and what steps were taken to determine it was a write off. Be detailed.
Attach the “write off” and appropriate “RFNP- Therapist OON” labels to claims in Apero
Mark tasks as “Done”
Scenarios and Statuses for Sending Voided Claims in Apero
Retool/Freshdesk Process:
End insurance coverage and set cash pay coverage for the date of discovery moving forward.
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.
Resend current GFE.
Email the member via Freshdesk using the canned message below:
Canned Message in FD: “Claims - Therapist is OON with Member's Plan”
IMPORTANT:
After sending the email, change the status of the ticket to “Open” and the group
to “Transfers.”
Leave a note on the ticket to “If the member requests a transfer, pair the member with a therapist in network with “X” plan.”
If a copay was charged, waive the copay and refund the member.
If you do not have access to issue a refund, reach out to a manager.
Make notes in retool on all of the steps above.