SelectCare/LaborCare Life of a Claim

Medica SelectCare/LaborCare Life of a Claim Purpose

In this class, participants will learn the repricing process for non-remote payer claims related to Medica SelectCareSM and LaborCare® products, the claims process for remote repricers, as well as an overview of the Medica SelectCare and LaborCare products.

Objectives

Upon completion of this class you will be able to: • Identify non-remote and remote clients • Understand the process to reprice a claim for non-remote clients • Understand the process for remote repricer clients

Topics

This course is divided into the following topics:

Topic . Overview of Medica SelectCare/LaborCare

2

2. Network Options 6 3. Timely Filing & Reimbursement Policies 8 4. Credentialing & Demographics 9 5. Claims Process for Non-Remote Payers 10 6. Remote Repricers 16 7. UnitedHealthcare® 17 8. Aetna® 22

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1. Medica SelectCare/LaborCare Overview

What is a PPO? TPA – Third Party Administrator

Both SelectCare and LaborCare are Preferred Provider Organizations (PPO) products sold by Medica. The service area is Minnesota, western Wisconsin, and North & South Dakota. Preferred Provider Organizations (PPOs) are an alternative approach to managed care. In a PPO, contracts are established with providers in order to form a network. Providers under such contracts are referred to as Preferred Providers. Employer groups, Third-Party Administrators (TPAs), union funds, and other plan sponsors contract with PPOs to utilize the provider network. PPOs are not subject to state regulations and mandates that govern Health Maintenance Organizations (HMOs). A TPA is a company that is hired by an employer group, union fund, or other plan sponsor to administer healthcare benefits for the group’s employees or the plan sponsor’s covered persons. The TPA, oftentimes referred to as the “payer,” maintains enrollment, manages the benefit plan, processes and pays claims; however does not assume the risk for the cost of the medical services. The employer group, or other plan sponsor that hired the TPA, assumes the financial risk. Usually, the TPA will contract with a PPO only for network access. Below is a diagram that illustrates these relationships:

EMPLOYER GROUP

THIRD PARTY ADMINISTRATOR

PREFERRED PROVIDER ORGANIZATION

PREFERRED PROVIDER NETWORK

UNION FUNDS

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ID Cards LaborCare ID Card Sample

IDENTIFICATION CARDS The TPA produces the enrollee’s ID card. Therefore, the cards will vary in style and content. However, cards will include either the SelectCare or LaborCare logo1, the TPA’s group number, the enrollee’s identification number, the claim submission address and appropriate customer service numbers. If the enrollee’s ID number is not on the card, ask for it (some people write it on their card). Sample ID cards are shown below. This is an example of a Pipe Trades Services MN ID card – front only:

1 If a UHC SelectCare enrollee resides outside of the SelectCare/LaborCare service area, only the EOB/ EOMB will show the logo.


SelectCare ID Card Samples

This is an example of Benefit Plan Administrators (BPA) ID card – front and back:

Example of WPS reciprocity wrap ID card - front and back (note: This enrollees wrap network is excluded for Wisconsin – the ID card specifies MN, ND, and SD only):


Client Types Non-Remote Clients Remote Clients Eligibility and Benefits

CLIENT TYPES SelectCare/LaborCare has two types of clients: • Non-remote • Remote Non-remote refers to clients whose claims are submitted to the SelectCare/LaborCare claims address, repriced according to the contracted rates and then forwarded to the client (or payer) for payment determination. In this guide, these clients will be referred to as “payers.” Examples of non-remote clients are: • Expert Benefit Solutions (EBSO) • Benefit Plan Administrators (BPA) • Pipe Trades Services MN • UMR • Zenith American Solutions Remote clients are those who load the purchased network and payment rates in their adjudication system. Claims are submitted directly to the remote client, who reprices the claim and makes the payment determination. In this guide, these clients will be referred to as “remote repricers.” Remote clients: • UnitedHealthcare • Aetna SelectCare/LaborCare does not maintain eligibility or benefit information. Therefore, providers should contact the payer or remote repricer to verify benefit and eligibility information. Please do not call SelectCare/LaborCare for benefits/eligibility. Since the payer or remote repricer is responsible for claims payment determinations, providers should contact the payer or remote repricer for questions regarding claims payment. Go to medica.com at the following locations for a link to payers contact information: Providers>Electronic Transactions>Log in>Eligibility Inquiry Or Providers>Administrative Resources>Product Information>Commercial Products – Medica SelectCare / LaborCare > PPO Payer List


2. Network Options

Network Options SC PPO Network SC PCP Network LC PPO Network LC PCP Network

SelectCare/LaborCare offers several different network options. There are four medical networks, a chiropractic network and a mental health network. Each payer/remote repricer has the option to access an entire network or only portions of a network. The payer or remote repricer will make the decision based on whether they feel that SelectCare/LaborCare has adequate access standards in a particular area or region. Aetna, for example, only accesses certain counties in Minnesota, portions of eastern North Dakota, and portions of western Wisconsin. They do not utilize the network in South Dakota. NETWORKS SelectCare PPO Network This is an open access network utilizing the SelectCare PPO network of preferred providers. Enrollees do not require written referrals. The purchase of care management services is optional. SelectCare Primary Care Physician (PCP) Network This is a care system network utilizing the SelectCare PCP network of preferred providers. Enrollee’s must designate a PCP and care is directed by the PCP. Care management services are administered by the payer/remote repricer. Currently, only Aetna purchases this network. LaborCare PPO Network This is an open access network that is a combination of the SelectCare PPO preferred providers and certain Medica Choice contracted providers. Referrals are not required. The purchase of care management services is optional. LaborCare PCP This is a care system network that utilizes the LaborCare PCP network of preferred providers. Enrollee’s must designate a PCP; care is directed by the PCP. Care management services are administered by the payer/remote repricer. Currently, only UHC purchases this network. Network Options (cont’d)


Medica Behavioral Health Medica Behavioral Health manages the behavioral health network. Payers and remote repricers are not required to purchase the behavioral health network.2 Medica Behavioral Health provides the contracting, credentialing and utilization management, if purchased. Chiropractic Network Health Services Management (HSM) manages the chiropractic network. Payers and remote repricers are not required to purchase this network.3 HSM provides the contracting, credentialing and utilization management.

2 Providers should contact payer or remote repricer to determine which behavioral health network is utilized. 3 Providers should contact payer or remote repricer to determine which chiropractic network is utilized.


3. Timely Filing and Reimbursement Policies

Reimbursement Policies

Timely Filing Timely filing is a term used to reference the length of time providers or enrollees are afforded to submit claims or adjustments to SelectCare/ LaborCare payers/remote repricers for payment determination. SelectCare/LaborCare requires that all original claim submissions must be received at the designated claims address no more than 180 days after the date of service, or the date of discharge for inpatient claims. SelectCare/LaborCare payers and remote repricer’s policies cannot be more restrictive than 180 days; however they can be less restrictive. In other words, a payer could allow 365 days for submission, but could not restrict it to 100 days for submission. There are some exceptions to the 180-day filing limit: • Coordination of Benefits (COB) when the SelectCare/LaborCare payer is

the secondary payer • Patient’s date of birth is less than one year before the date of service • Enrollee enrollment delays for COBRA continuation coverage • Itemized billing for obstetric care and delivery • Radiation treatment management services SelectCare/LaborCare has an 18-month final filing limit. Claims or requests for adjustments must be received within 18 months of the date of service. Refer to the SelectCare/LaborCare Administrative Manual for further clarification regarding timely filing at Medica.com at this location: Providers> Administrative Resources Reimbursement Policies Each payer or remote repricer is responsible for determining their own reimbursement policies. Therefore, policies will vary depending upon the payer or remote repricer. For example, one payer/remote repricer may cover venipuncture as a separately billable charge, while another payer/remote repricer may deny the venipuncture as incidental. If a provider disagrees with how a claim was processed, the provider should contact the payer or remote repricer to determine what the reimbursement policy is. Some payers/repricers have their reimbursement policies available on their websites. Contractually, a provider cannot balance bill the enrollee (Examples include Aetna and UnitedHealthcare).


4. Credentialing and Demographics

Demographic Changes

In this section, we will review the credentialing of providers and demographic change requests. SelectCare/LaborCare follows Medica’s credentialing guidelines. Medica accepts the Minnesota Uniform Credentialing Application for individual applicants. Medica will return applications submitted on any other form. The form is available on Medica.com at this location: Providers> Administrative Resources>Credentialing The completed application should be returned to the Credentialing Department with all appropriate attachments. Applications should be submitted at least one month prior to an individual provider’s start date at a clinic. It is very important that credentialing is done in advance, as the remote repricers will not accept retroactive effective dates. Demographic Changes Maintaining current and accurate provider demographic data is a critical factor in accurate and timely claims payment, as well as the printing and distribution of accurate and current provider directories. Providers may make a demographic change to a physician/practitioner or a clinic/site by completing the appropriate forms located on Medica.com at this location: Providers>Administrative Resources>Demographic Change>Demographic Change Requests Completed forms should be returned to Medica, not the SelectCare/ LaborCare claims address. Because Medica electronically sends all provider information to UHC and Aetna on a weekly basis, it is very important to submit any demographic changes to Medica prior to the date of the change. This allows Medica time to update our system and the remote repricers time to change their systems. It is not necessary for the provider to submit changes to UHC or Aetna; Medica will send the changes electronically.


5. Claims Process for Non-Remote Payers

Claim Submission Claims Address

Turn-Around Time

As noted previously, SelectCare/LaborCare has two types of clients, non-remote payers and remote repricers. In this section we will discuss the claims process for non-remote payers. Claims for services received by enrollees enrolled through non-remote payers should be submitted to SelectCare/LaborCare. SelectCare/LaborCare then reprices the claims through our repricing system. After repricing, the repricing information and claims are forwarded to the payer for payment determination. The repricing of a claim does not guarantee either that the patient is an active enrollee or that the service is a covered service. SelectCare/LaborCare does not hold enrollment or benefit information. Paper claims should be submitted to: PO Box 830489 Birmingham, AL 35283-0489 Electronic claims should be submitted to: Electronic ID 00014 The expected turn-around time for SelectCare/LaborCare claims payment is 45 days. This allows time for the claims to be repriced, adjudicated and paid by the appropriate payer. Repricing does not guarantee payment and the claims are not subject to the 30-day prompt pay requirements. However, SelectCare’s contracts with payers require that clean claims are paid within 30 days of the payer’s receipt. If you have evidence that a payer is consistently paying clean claims beyond 30 days, gather examples and contact the Provider Service Center. Claims Process for Non-Remote Payers (cont’d) Electronic Claims Process

1) Provider submits claim through their Electronic Data Interchange (EDI) vendor to electronic ID 00014.

2) The EDI vendor transmits the claim to the SelectCare/LaborCare repricing system.

3) The claim is repriced and a facesheet is created with repricing information.

4) The facesheet and claim is forwarded to the payer. a) outbound claim file. The payers that receive an outbound claim


Sendback Process

file are the following: Benefit Plan Administrators (BPA), Centurion, EBSO, Pipe Trades Services MN, WPS, and Zenith American Solutions.4

b) Dropped to paper and mailed to the payer. The payers that are not set up to receive an outbound claim file are the following: Interactive Medical System (IMS), Mayo Clinic Health Solutions, Self Insured Plans, The Benefit Group, and UMR.

5) The payer makes a benefit and a payment determination. 6) The payer informs the provider of the benefit determination and makes

payment, if any. Paper Claims Process

1) Provider submits claim to SC/LC claims address per the ID card. 2) Upon receipt, claims are scanned and sent through Optical Character

Recognition (OCR), verification and keying processes. 3) Claims are then sent through the repricing system which applies the

appropriate fee information and reprices the claim. 4) Facesheet with repricing is printed. 5) Claim, facesheet and any corresponding attachments submitted with

the claim are forwarded to the payer. 6) Payer makes benefit and payment determination. 7) The payer notifies the provider of the benefit determination and makes

payment, if any. (Note: HSM providers’ claims should be submitted directly to HSM.) Sendback Process on Rejected Claims During the initial processes and repricing, claims can be rejected back to the provider, for various reasons. Examples include: • Illegible data • Minimized/shrunken claim form • Faxed claim copies • Carbon copies • Claims not submitted on standard CMS1500 or UB-04 claim forms • Invalid service codes • Missing employer group information • Missing enrollee information • Claims with illegible handwritten data elements Claims Process for Non-Remote Payers (cont’d)

4 There are a small of portion of claims that are received electronically that will be dropped to paper and forwarded to a payer for various reasons.


Avoid Rejections

Invalid Group Number

In order to avoid rejections, providers should: • Bill the claim with complete, legible and valid information on a CMS1500

or UB-04 claim form • Bill the claim with the exact group number from the ID card • Bill the claim with the exact provider data that Medica has loaded • Bill the claim with valid codes • Submit claims for one member and one provider per claim form • Submit one attachment (e.g. EOB) per form There are two common reasons claims are rejected and sent back to the provider — invalid group number and invalid provider information. Next, we will review causes of these errors and how to remedy them. Invalid Group Number SelectCare/LaborCare does not hold “positive enrollment,” meaning that payers have not provided Medica any enrollment data to determine if an enrollee has active coverage. SelectCare/LaborCare only validates if the group number is an effective group number. If the group number is effective, the claim will be repriced and sent to the payer. If the group number is not valid, the claim will be returned to the provider with a letter stating, “The group number/name is missing or invalid.” An example of this letter is on page 13 of this guide. This can be caused by several reasons:

a) The payer did not notify Medica of a new group. It is the payer’s responsibility to notify Medica whenever a new group becomes effective.

b) The group number listed on the ID card does not match the group number that the payer notified Medica of. For example, the group listed the group number to Medica as 123. However, the ID cards were issued with a group number 123-01. The claim system looks for an exact match.

c) The provider adds additional characters to the group number box. For example, the group number on the card is 123. On the claim, the provider lists the group number as 123CBSA.

If you receive a sendback letter for invalid group number and the group number submitted matches the card, contact Medica’s Provider Service Center. The Provider Service Center will have the issue researched and updated in the system. Claims Process for Non-Remote Payers (cont’d)


Sendback Example for Invalid Group Number

Invalid Provider Information Example

Provider Information It is very important that providers submit information in Boxes 31 and 33 of the CMS-1500 that exactly matches the way the provider was set-up in the Medica system. SelectCare/LaborCare utilizes the practitioner name, clinic name, claim address, and federal tax identification number for provider matching. If we are not able to make a participating provider match, the claim will process as out-of-network. Example Provider was credentialed as John Smith, M.D. The record will be loaded as John Smith, M.D. If the claim is submitted with J. Smith, rather than John Smith, M.D., our system will process as out-of-network as it would not locate an exact match. Claims Process for Non-Remote Payers (cont’d)


Adjustment Requests

Adjustment Requests Providers should only request an adjustment from Medica if the claim was not repriced according to the provider’s contract, as Medica does not pay claims, determine benefits, or apply coding logic. A provider’s first step when questioning claims payment should be to contact the payer. The payer will apply the appropriate benefits and can apply their own coding logic, so this will affect the outcome of the final payment to you. If, after contacting the payer, you determine that the claim was repriced incorrectly, you can request an adjustment one of the following ways:

1) Complete the SelectCare/LaborCare Adjustment Request form on Medica.com and send it to the SelectCare/LaborCare claims address or

2) Call the Provider Service Center and request an adjustment. An example of the SelectCare/LaborCare Adjustment Request form is on following page. It is also located on Medica.com at the following location: Providers>Administrative Resources> Product Information>Commerical Products-Medica SelectCare / LaborCare>Claim Appeal Request From Claims Process for Non-Remote Payers (cont’d)


Adjustment Request Form


6. Remote Repricers

Remote Repricers

As noted previously, remote repricers are those that purchase the SelectCare/LaborCare network, load the network and appropriate contracted payment information in their adjudication system, and reprice and pay the claims with no intervention from SelectCare/LaborCare. When a provider signs a SelectCare/LaborCare contract, the provider agrees to participate with the various TPAs and remote repricers with whom SelectCare/LaborCare contracts. Currently, SelectCare/LaborCare contracts with two remote repricers: • UnitedHealthcare • Aetna Claims for services for enrollees utilizing the SelectCare/LaborCare network should be submitted directly to the remote repricer, not the SelectCare/ LaborCare claims address. Each remote repricer accepts electronic claims. As discussed previously, Medica provides the remote repricers with our network and contracted rate information. It is extremely important that providers submit claims in which the demographic information matches the demographic information that Medica has provided the remote repricers. If a provider’s information is submitted differently, it is likely that the remote repricer will be unable to match the claim with a network provider. Claims will be returned to the provider, denied or processed at an out-of-network benefit level, if applicable. The turnaround time for clean claims processing is 30 days from the date of the receipt of the electronic claim.


7. UnitedHealthcare

UHC Products

UnitedHealthcare (UHC) is one of two current SelectCare/LaborCare remote repricers. LaborCare is the network for UHC enrollees who reside in the SelectCare/LaborCare service area. As noted previously, UHC is a remote repricer. Medica electronically provides UHC the LaborCare network and associated contracted rates. UHC loads this information into their claims adjudication system. Claims are submitted directly to UHC. UHC Products UHC offers several products. All UHC products, with the exception of UHC Indemnity utilize the LaborCare network The four most often purchased in our service area are: UnitedHealthcare Options PPO: Enrollees on this plan can choose any network physician or healthcare professional without a referral and without designating a primary care physician. The plan provides out-of-network coverage and enrollees are responsible for notifying UHC for services requiring notification. UnitedHealthcare Select and Select Plus: Enrollees on this plan choose a Primary Care Physician (PCP) for each family member from the network of physicians. The PCP coordinates patient care and recommendations for network specialists when necessary. Written referrals are not required. Select provides in-network coverage only; Select Plus provides both in-network and out-of-network coverage. The treating physician is responsible for notifying UHC for services that require notification. UnitedHealthcare Choice and Choice Plus: Enrollees can choose any network physician or healthcare professional without a referral and without designating a PCP. The treating physician is required to notify Care Coordination on services that require notification. Choice provides in-network coverage only; Choice Plus provides both in-network and out-of-network coverage. UnitedHealthcare Indemnity: Enrollees have access to any physician or healthcare professional and no network is utilized. Enrollees are responsible for notifying Care Coordination for services that require notification. The LaborCare discount will NOT apply. UnitedHealthcare (cont’d)


Cards and EOBS Mental Health and Chiropractic

Reciprocity UHC has a reciprocity arrangement with LaborCare that allows any enrollee, with the exception of those on indemnity plans, to access a LaborCare provider. What this means is that any enrollee on a non-indemnity UHC plan can access a LaborCare provider and receive the benefit of the LaborCare discount. Example A UHC enrollee on a Choice Plus plan who resides in California travels to Minnesota for business. During the trip, the enrollee visits a LaborCare provider and receives services. The claim will be processed with the LaborCare discount. Cards & Explanations of Benefits Enrollees who reside in the LaborCare service area (Minnesota, western Wisconsin & eastern North and South Dakota) will have a card with the LaborCare logo. If an enrollee resides outside the LaborCare service area, the card will have the logo of the enrollee’s “home” network only. All Explanations of Benefits (EOBs) on which a LaborCare discount was taken will have the LaborCare logo, regardless of the enrollee’s “home” network. Behavioral Health & Chiropractic Services UHC does NOT access either the behavioral health network or chiropractic network sold by SelectCare/LaborCare. UnitedHealthcare (cont’d)


Claim Submission

Claims Submission

NOTE: Please refer to the enrollee’s ID card for claim submission information.

Contact Information A provider’s first point of contact with questions regarding claims payment or disputes regarding claims payment is UHC. UHC offers several options for providers to utilize to contact UHC service representatives. Providers can access UHC’s Voice Enabled Telephone Self-Service System (VETSS) at 877-842-3210. This line can assist providers with eligibility, benefits, claim status and appeals. This is an automated voice response system. If at any time a provider wishes to speak with a live representative, the caller should state “Customer Service.” The caller will then be transferred to a representative. Providers may also call the Provider Service number listed on the enrollee’s ID card. UHC also has a website which can be accessed to review eligibility & benefit information, provide inpatient facility notification, check claims status, view reimbursement policies, submit adjustment requests, etc. The website address is:

https://www.unitedhealthcareonline.com

As stated earlier, a provider’s first point of contact to resolve issues regarding services provided to UHC enrollees should be UHC. If the provider is unable to resolve the issue with the UHC representative, providers should request a supervisor. If, after escalation to a supervisor, the issue remains unresolved, providers may contact Medica’s Provider Service Center for assistance. Providers will be expected to supply the names of all UHC representatives spoken with regarding the issue, as well as any and all attempts made to resolve the issue directly with UHC. UnitedHealthcare (cont’d)


https://www.unitedhealthcareonline.com/

Appeals/Adjustments UHC has many options available to providers to request an appeal or adjustment. Individual adjustments and appeals can be requested using the UHC Reconsideration Form, available at www.unitedhealthcareonline.com. Additionally, adjustments can be requested on UnitedHealthcare Online. A resubmission of an electronic claim does not constitute an appeal. Typically, the resubmission will be denied as a duplicate. Providers should use the UHC Reconsideration Form when:

a) Reconsideration requires supporting documentation (such as primary carrier’s EOB, corrected claim, proof of timely filing).

b) Reconsideration for an appeal that already has an existing record and the provider was unable to submit the appeal online.

c) Reconsideration on paper required for appeals of a previously denied appeal.

The form should be completely filled out. Providers should not eliminate any of the checked boxes on the form. Providers should not complete one reconsideration form for multiple enrollees with a batch of claims. One reconsideration form should be done per enrollee. UHC Online should be used to request adjustments/appeals when…

a) A claim is paid or denied incorrectly and no supporting documentation needs to be submitted

b) A claim did not pay according to contract allowable. When using UHC Online for adjustment requests, it is important that providers remember…

1) To be very specific and include as much information as possible for the processor in the detailed description of why you are requesting reconsideration.

2) To document the tracking number that you receive upon submission of the appeal. The tracking number will be assigned if the issue is able to be routed and there is no existing record for the same claim. This tracking number will assist you in following-up with UHC on your appeal.

3) That you are not able to submit an appeal online for those claims that were previously submitted on paper or that you have previously questioned. Providers will receive an error when clicking on the submit button, if a duplicate issue exists.

UnitedHealthcare (cont’d)


http://www.unitedhealthcareonline.com/

Appeals and Adjustments (continued)

Additionally, providers can utilize UHC Online to request adjustments on batches of 20 or more claims. All claims included in the batch should be denied or incorrectly paid in the same manner. Batches should not include multiple issues. It is important that providers include as much information as possible. A detailed description does need to be entered for each claim; however you can copy and paste the same description for each claim. Providers may also submit appeals in a letter format with an explanation. The more precise the provider is in the explanation of the issue, the better the chances are it will be handled appropriately. Please do not leave the appeal open to interpretation. (For example, do not simply say “see attached.”) UHC may respond to your appeal in a letter format or via a remittance advice. Providers should post this response in their practice management system. Care Coordination It is important that providers notify UHC of services that require notification. Failure to notify may result in complete denial of payment for both the facility and accompanying physician charges. A complete list of notification requirements is available in the UHC Administrative Manual available on UnitedHealthCareOnline.com UHC must be notified within one business day of: • Emergency facility admissions • Home Health or Inpatient Admission after ambulatory surgery UHC must be notified, at least five business days in advance (in cases in which admission is scheduled less than 5 business days in advance, notification should be done at the time the admission is scheduled) of: • Non-emergency admissions (except maternity) Providers may provide notification to UHC one of two ways:

1) Through UHC Online 2) By calling 877-UHC-3210 (877-842-3210)


8. Aetna

Contact Information

Aetna is the second of two current SelectCare/LaborCare remote repricers. Aetna utilizes the SelectCare network. Aetna, however, only accesses certain counties in Minnesota, portions of North Dakota and portions of western Wisconsin. Aetna does not access the SelectCare network in South Dakota. Aetna offers both PPO open access plans and PCP care system plans. PCP plans require written referrals for care outside of the PCP’s federal tax ID. Claim Submission Aetna ID cards may list various claims addresses. Please refer to the ID Card for claim submission information Provider Service Center : 888-632-3862 Contact Information It is expected that providers will first attempt to resolve issues directly with Aetna. Providers will need their Aetna Provider ID which is listed in the Aetna provider directory. Aetna currently offers a Voice Response Unit (VRU) at 888-833-8825, and there is information available at NaviNet.com on claim status, claim denials, EOB’s, etc. Providers can utilize the VRU to verify eligibility, enter referrals, check on referrals, do pre-certification and check claim status. The VRU system will go through each step using your touch-tone keypad for response. Providers will need their Aetna Provider ID, also referred to as the Aetna PIN number. This number is listed in the Aetna directory. On NaviNet.com providers can: • verify eligibility • check claim status • review claim payment policies and code editing logic with clinical rationale • submit a referral • check referral status • search DocFind, Aetna’s online physician referral directory • locate PIN numbers Access NaviNet login on medica.com: Providers>Administrative Resources> >Product Information>SelectCare LaborCare>NaviNet login


Appeals & Reconsiderations

Appeals and Reconsiderations Aetna has a formal process for practitioners, hospitals and other facilities to follow when they do not agree with a claim payment decision or do not agree with a clinical decision regarding an Aetna enrollee. Aetna has three levels of appeals, however not all providers have access to all three levels. Aetna allows practitioners (defined as an individual licensed or otherwise authorized by state in which he/she practices to provide healthcare services, e.g. physicians, podiatrists) access to all three levels. However, providers defined as institutional provider and supplier of healthcare services, e.g. hospitals or Skilled Nursing Facilities (SNFs), only have access to Reconsideration and Level 1 Appeals, unless state law allows additional levels. The three steps are: • Level 1 Appeal ─ oral or written request that asks Aetna to change an

adverse decision • Level 2 Appeal ─ oral or written request to change a Level 1 adverse

decision. • Level 3 Appeal ─ oral or written request are handled by the Medical

Director. © 2009-2010 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured and Medica Health Management, LLC. Medica SelectCareSM is a service mark of Medica Health Plans. LaborCare® is a registered service mark of Medica Health Plans.


SelectCare/LaborCare Life of a Claim

Documents

Transcript of SelectCare/LaborCare Life of a Claim