Questions to ask yourself in this process: 

Did the member upload a different insurance plan?

If the member did upload a different insurance plan, is that their primary and are we in network?
Is Retool showing a primary and secondary insurance coverage?

How does it differ from what’s happening in Apero?



Scribe Link for “Claims - Coordination of Benefits”


Apero/Claims Process:

  1. Confirm the claim denied correctly for needing the primary insurance EOB.

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

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

  3. See if the member uploaded a different insurance plan in Retool

    1. If no, then proceed with step 4 below

    2. If yes, then verify eligibility, in network status, determine COB, and rebill claims to the primary insurance plan. Your workflow ends here.

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

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

  6. Attach the “Write off” and “RFNP - COB” labels to claims in Apero

  7. 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? 

Claim denied for COB/needing primary insurance EOB

No

Void

Denied

No




Retool/Freshdesk process:

  1. Check eligibility flow to confirm that no new insurance cards have been uploaded.

    1.  If no, proceed below. 

    2. If yes, verify insurance before proceeding below. 

  2. 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.

  3. Under “Insurance Card Upload Status” select the drop down “request insurance cards” and click “Save Ins Card Upload Status.”

    1. This action sends the member a text message to upload their new insurance card

  4. Resend current GFE.

  5. Email the member via Freshdesk with the canned message below:

    1. Canned Message in FD: “Claims - Coordination of Benefits”

  6. 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. 

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