Directprovider.com section 2 11072013

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  • 1. FREEdom to go direct Directprovider.com Training Presented by Coventry Health Care
  • 2. Coventry Health Care – For Public Use In Section Two, the following will be covered:  Claim Inquiry — Searching for Claims — Viewing Claim History and Detail — Requesting Adjustments  Claim Submissions (via Emdeon)  Remittance Advices  Message Center — Composing and Working with Health Plan and Workers Comp Messages  Coventry National PPO Fee Schedule — Requesting Current Fee Schedules — Requesting Future Fee Schedules  Coventry National Client Listing  First Health /TPA Carrier Bills  Workers Comp — Bills — Jopari Portal — Refer a Patient (Talispoint) — Provider Resources Directprovider.com – Section Two
  • 3. Coventry Health Care – For Public Use Claim Inquiry… This section provides claim status, claim payment information, claim line detail, and claim history. The users are able to:  Search for claims  View specific or entire groups of claims  Submit an online claim adjustment  View/Print Remittance Advices
  • 4. Coventry Health Care – For Public Use Claim Inquiry…
  • 5. Coventry Health Care – For Public Use Claim Inquiry… Fields marked with an Asterisk are required On the Search By Member tab users can use the following Search Methods: - Member ID - Member Name/DOB
  • 6. Coventry Health Care – For Public Use Claim Inquiry… When searching by Member, if The member is found in multiple health Plans the user will be prompted to select the health plan and click CONTINUE
  • 7. Coventry Health Care – For Public Use Claim Inquiry… All date ranges are limited to 30 Days On the Search By Status tab users can search by date/date range from the following selected status: - Pended - Rejected - Denied - Approved - Paid - Unpaid
  • 8. Coventry Health Care – For Public Use Claim Inquiry… On the Search By Claim Number tab users can search by a known claim for the selected Tax ID #
  • 9. Coventry Health Care – For Public Use Claim Inquiry… On the Search By Date tab users can search by DOS or a 30 day date range for the selected Tax ID #/Health Plan/Provider
  • 10. Coventry Health Care – For Public Use Claim Inquiry – Search Results… Results Not Found For DENIED and REJECTED claims the use can click the icon to display a more detailed reason Click the icon to display processing History Click the icon to View Details for the selected claim
  • 11. Coventry Health Care – For Public Use Claim Inquiry – Reason… When a claim has been Rejected or Denied, the user can click the REASON button to display a more detailed reason for the denial or rejection
  • 12. Coventry Health Care – For Public Use Claim Inquiry – History… Click the HISTORY button to view the detailed processing history, which will include any Status changes
  • 13. Coventry Health Care – For Public Use Claim Inquiry – Detail… The claim header area includes the following detail: - Provider information - Claim type (Original, Backout, Replacing) - Date Entered/Approved - Referral/Authorization Number (if applicable) - Patient Control # (if applicable) - Coordination of Benefits Flag - Paid Amount - Eligibility Link for the DOS
  • 14. Coventry Health Care – For Public Use Claim Inquiry – Detail… The line detail area includes all line items submitted on the claim, Click the VIEW button in the disposition column to view detailed processing for the specific line item (click HIDE to close the expanded line item disposition details)
  • 15. Coventry Health Care – For Public Use Claim Inquiry – Detail… The Payment Information area will include a link to the Remittance Advice (if available) as well as detailed payment information and Patient Responsibility, the user can click the Print Friendly link to print out the claim detail EFT333333 ABC PEDIATRICS
  • 16. EFT333333 ABC PEDIATRICS 123456 987654321 Coventry Health Care – For Public Use Claim Inquiry – Detail… If a claim has been backed out and replaced the Related Claims area will be present and will have the other corresponding claims, the user can click on a corresponding claim number to view that detail
  • 17. 123456789 #123456789 80111111102SALLY PUBLIC Coventry Health Care – For Public Use Claim Inquiry – Adjustment Request… Clicking the Request Adjustment link will branch the user to the ADJUSTMENT REQUEST screen where the user will identify a Reason for the request from the drop-down and the Contact Information will default the users Name and Phone (but can be changed if necessary)
  • 18. Coventry Health Care – For Public Use Claim Inquiry – Adjustment Request… Users will populate the corresponding fields depending on the circumstances of their adjustment request
  • 19. Coventry Health Care – For Public Use Claim Inquiry – Adjustment Request… Users are able to attach up to four (4) electronic files not totaling more than 10 megabytes (click the Remove button if something has been attached in error); Click Submit Request when done
  • 20. Coventry Health Care – For Public Use Emdeon Claim Submissions… • Coventry has partnered with Emdeon to provide online claim submission (direct data entry or claim file upload) and HIPAA electronic remittance advice access for Coventry Health Care members at no cost to the providers • This web interface is a self-directed/administered solution that contains some of the functions a provider can use today within Emdeon Office • Providers that submit paper claims or are able to produce HIPAA compliant EDI claim and remittance (837 and 835) files may want to take advantage of this functionality
  • 21. Coventry Health Care – For Public Use Emdeon Claim Submissions…  Small offices that only see a few Coventry members may be interested in the direct data entry functionality 1. Manually enter claims directly to the Emdeon site (via Directprovider.com link) 2. Monitor return messages from Emdeon and later from Coventry regarding claim level accept/reject messages on the site 3. Fix or reenter any claims that are rejected as applicable  Larger provider offices that are able to create their own HIPAA compliant/EDI claim files might want to use the file upload process; however, they must be able to manage the full cycle of EDI claim submission: 1. Prepare HIPAA compliant 837 EDI file from billing system or vendor 2. Upload file to Emdeon website (via Directprovider.com link) 3. Monitor return messages from Emdeon and later from Coventry regarding claim level accept/reject messages 4. Fix or reenter any claims that are rejected as applicable
  • 22. Coventry Health Care – For Public Use Emdeon Claim Submissions…  The system will present the Claim Submission landing page when the left navigation link is invoked  When the user clicks <continue> the system will present Emdeon’s login page
  • 23. Coventry Health Care – For Public Use Emdeon RAs…  Within Remittance Advices, the system will present the HIPAA 835 Remittances landing page when the HIPAA 835 Remittances tab is selected  When the user clicks <continue> the system will present Emdeon’s login page
  • 24. Coventry Health Care – For Public Use Emdeon Claim Submissions/RAs…  Coventry will not have staff trained to support this tool; Provider office staff will need to reach out to Emdeon to request any additional information regarding this process  Provider offices can pre-load provider and practice details (Providers and the Practice must have NPIs)  Once logged in, WebConnect users will be able to select Direct Data Entry or Claim File Upload  All claims submitted through this process will be merged with all Coventry claims submitted under payer ID 25133
  • 25. Coventry Health Care – For Public Use Remittance Advices… Another option on the Navigation Bar is Remittance Advices (RAs). This section of Directprovider.com allows users to view remittance advices online. The remittance advice (RA) available on Directprovider.com is an exact image of the paper remittance advice sent through the mail. There will be three tabs to chose from (as applicable): — Health Plan Remittances — Coventry Consumer Choice/C3 Remittances — HIPAA 835 Remittances
  • 26. Coventry Health Care – For Public Use Remittance Advices… The Search Methods include: - Claim(S)# - Member ID - Member Name/DOB - Check/EFT # - Service Dates - Check/EFT Dates Click SUBMIT to Search
  • 27. Coventry Health Care – For Public Use Remittance Advices… Within the Search Results column click the View link to open the RA in an Adobe Reader (if you don’t have Adobe Reader installed click the Get Adobe Reader button to download a free version 123456789 EFT12345
  • 28. Coventry Health Care – For Public Use Remittance Advices…
  • 29. Coventry Health Care – For Public Use Secure Messaging… The Message Center is another alternative for Coventry providers to communicate private health information directly with the Coventry CSO. The Message Center option allows Coventry providers the opportunity to submit secure Health Plan specific and Workers’ Comp messages to the Coventry Customer Service Organization in regards to inquiries for claims, authorizations, eligibility, and forms, to just name a few. Secure messaging allows users to communicate private health information directly with the customer service organization.
  • 30. Coventry Health Care – For Public Use Secure Messaging…
  • 31. Coventry Health Care – For Public Use Secure Messaging… Click the Subject to open a message Select Health Plan or Workers’ Comp and click Go to compose a new message Common formatting is used to identify read/unread messages The Paper Clip icon is used to indicate an attachment
  • 32. Coventry Health Care – For Public Use Secure Messaging… When composing a new message select a Reference (Claim #,Member ID, or Other); select an applicable Category (such as Authorizations, Claims Adjustment, Eligibility / Benefits, Forms, etc.); and enter a Subject Users can attach up to 4 electronic data files (click Remove, to delete an attachment)
  • 33. Coventry Health Care – For Public Use Secure Messaging… Click the Message List button to return to the Inbox tab Click Cancel to close or Reply to respond Click Trash to move to the Trash tab or click Print Friendly to print the message
  • 34. Coventry Health Care – For Public Use PPO Fee Schedules…  Physicians and Ancillaries not affiliated with a Hospital who participate with any of the Coventry National PPO Products are able to request Fee Schedule detail through Directprovider.com  Eligible providers must be registered with one or more of the Coventry National PPO Products before they can submit a Fee Schedule Request  Eligible providers may request Current or Future Fee Schedules and can designate whether they want to receive Full Schedules; Sample Schedules; a Procedure Code Range; or a Single Procedure code
  • 35. Coventry Health Care – For Public Use PPO Fee Schedules… Users with access to the PPO Fee Schedule functionality will select the applicable Tax ID #, Provider and PPO Product from the drop down and then click the Submit button (Users who do not have access will need to contact their Administrator to request access
  • 36. Coventry Health Care – For Public Use PPO Fee Schedules… Providers may have location specific rates, users will click the Select button for the desired Rate Code and Practice Location
  • 37. Coventry Health Care – For Public Use PPO Fee Schedules… Users will click the Current or Future SELECT button
  • 38. Coventry Health Care – For Public Use PPO Fee Schedules… Select the desired Search Method (with a Future request select Changed Values for only changing codes/values) and a desired Delivery Method; PDF Format (Preferred, as detail is returned within 24 hours) or US Mail (may take 10 to 15 business days to be returned)
  • 39. Coventry Health Care – For Public Use PPO Fee Schedules… When requesting Fee Schedules in PDF Format, the schedule will be delivered via a Secure Message; the Secure Message will include a link to open the schedule in PDF Format
  • 40. Coventry Health Care – For Public Use PPO Fee Schedules…
  • 41. Coventry Health Care – For Public Use Client Listing…  If a new administrator is registering to access the Client List functionality, he or she will access the section of registration that is labeled PPO Fee Schedule or Client List. — A user will identify that he or she is registering for Client List and will then have to supply his or her CPD ID to continue registration.  Existing administrators with PPO Fee Schedule access can add/edit the Client List Group; The user identifies will edit the Client List group. — If the user chooses to edit the Client List group, then a new page will display requiring TIN and CPD ID to be added to the Client List functionality.
  • 42.  Users with access will have the ability to access Client Lists via a link on the left Navigation Menu.  When the link is invoked, a disclaimer page is presented. The user has to accept the disclaimer to continue to the Client List landing page.  Users will enter search criteria and execute search.  There are six required fields that must be completed in order for the ‘Find Clients’ button to be accessible.  There is one optional field to search by client/payor name. Client Listing… Coventry Health Care – For Public Use
  • 43. Client Listing… Coventry Health Care – For Public Use Users with access will click the ACCEPT AND CONTINUE button (if you do not have access contact your Administrator to request access)
  • 44. Client Listing… Coventry Health Care – For Public Use Enter the required Search Options; For Only Show select from: - Clients Active Today - Clients that will be active in 30 days - Clients that will be active in 60 days - Clients that will be active in 90 days
  • 45. Client Listing… Coventry Health Care – For Public Use Users can search for a specific Client or Payor (optional, leave blank a complete Client List, then click the FIND CLIENTS button
  • 46. Client Listing… Coventry Health Care – For Public Use A list of Clients is returned based on search criteria entered; to view the Client Detail click the Show Detail button for the specific client (users can also download the list to Excel)
  • 47. Client Listing (Detail)… Coventry Health Care – For Public Use
  • 48. First Health TPA… Coventry Health Care – For Public Use Users can search/review First Health TPA carrier bills; Select the SEARCH by Patient or SEARCH by Provider tab and then enter the desired Search Criteria
  • 49. For Search By Patient: — Users can search by Claim Number, with optional Service Dates — Users can search by Patient Name / Date of Birth with optional Service Dates — Users can search by Patient SSN with optional Service Dates First Health TPA… Coventry Health Care – For Public Use
  • 50. For Search By Provider: — Users can search by Physician Name, with required Service Dates — Users can search by Billing Provider Name with required Service Dates — Users can search by Service Dates (maximum 30 day date range) First Health TPA… Coventry Health Care – For Public Use
  • 51.  If no Bills are found based on the entered search criteria, the user will receive a message to broaden the search criteria or search with a different category First Health TPA… Coventry Health Care – For Public Use
  • 52. First Health TPA… Coventry Health Care – For Public Use If Bills are found based on the entered search criteria, users will be able to: 1. Filter the Bill List results 2. Customize the viewable columns 3. Sort on most columns 4. Use the Action icon to display: the Medical Claims Pricing Systems (MCPS) Sheet or Send Inquiry 1 2 3 4
  • 53. First Health TPA… Coventry Health Care – For Public Use Filter options include: - Physician Name - Patient Name - Billing Provider Name Once options are checked the user will click Update Results to filter the Bill List
  • 54. First Health TPA… Coventry Health Care – For Public Use The Customize Table button allows users to pick and choose display fields (by checking or un-checking fields), at least 5 fields must be selected before the user can click OK
  • 55. First Health TPA… Coventry Health Care – For Public Use The user can click the Action icon and select PRICING SHEET to view the MCPS Pricing Sheet in PDF format or click SEND INQUIRY to send a Secure Message to the TPA CSO
  • 56. First Health TPA… Coventry Health Care – For Public Use
  • 57. Coventry Health Care – For Public Use First Health TPA… The user can click the Action icon and click SEND INQUIRY to send a Secure Message to the TPA Carrier CSO for assistance with bill disputes (Users may also request assistance with a category of ‘Other’ to get help with contract questions or even concerns with the quality of service they believe they are getting.
  • 58. Coventry Health Care – For Public Use  Clicking on the “Send Inquiry” option will open a separate window to enter the message detail. The Tax ID #, CPD ID # and Claim # will default Select an applicable Category from the drop down Enter the Subject and body of the message Up to 4 attachments (10 MB) can be attached Click ‘Submit’ to send First Health TPA…
  • 59. Coventry Health Care – For Public Use  The inquiry is sent through Navigator to the TPA CSO Web Inquiry queue for processing and response  The message will appear in the Inbox tab in the Directprovider Secure Message Center with an issue number assigned by Navigator from “First Health/TPA”  Users can reply to the message from the Message Center First Health TPA…
  • 60. Workers’ Comp – Landing Page… Coventry Health Care – For Public Use
  • 61. Workers’ Comp - Bills… Coventry Health Care – For Public Use The Bills function allows users to SEARCH By Bill, Patient or By Provider SEARCH By Bill Criteria: - Control # - Document ID
  • 62. Workers’ Comp - Bills… Coventry Health Care – For Public Use SEARCH By Patient Criteria: - Claim Number - Patient Name / Date of Birth - Patient SSN
  • 63. For Search By Patient: — Users can search by Claim Number, with optional Service Dates — Users can search by Patient Name / Date of Birth with optional Service Dates — Users can search by Patient SSN with optional Service Dates Workers’ Comp - Bills… Coventry Health Care – For Public Use
  • 64. For Search By Provider: — Users can search by Physician Name, with required Service Dates — Users can search by Billing Provider Name with required Service Dates — Users can search by Service Dates (maximum 30 day date range) Workers’ Comp - Bills… Coventry Health Care – For Public Use
  • 65. Workers’ Comp - Bills… Coventry Health Care – For Public Use If no results can be found the user will be advised to broaden their search criteria of call Customer Service
  • 66. Workers’ Comp – Bills… Coventry Health Care – For Public Use If Bills are found based on the entered search criteria, users will be able to: 1. Filter the Bill List results 2. Sort on most columns 3. Use the View Details button to display details and options for the selected bill 1 2 3
  • 67. Workers’ Comp – Bills… Coventry Health Care – For Public Use Filter options include: - Physician Name - Patient Name - Billing Provider Name Once options are checked the user will click Update Results to filter the Bill List
  • 68. Workers’ Comp – Bills (View Details)… Coventry Health Care – For Public Use Click the View Details button for additional claim detail and the following options: - View Bill Image (if applicable) - View EOR or Network Pricing Sheet (as applicable) - Send Inquiry (Secure Message) 01/18/2012 54321 203.89 153.8912/06/2011 279.00 if no payment info is available a message to contact the Vendor for payment details
  • 69. Workers’ Comp – Bills (Pricing Sheet)… Coventry Health Care – For Public Use
  • 70. Workers’ Comp – Bills (Bill Image)… Coventry Health Care – For Public Use
  • 71. Coventry Health Care – For Public Use Workers’ Comp – Bills (EOR Image)…
  • 72. Coventry Health Care – For Public Use Workers’ Comp – Send Inquiry… The Send Inquiry option for Workers’ Comp is a comprehensive Secure Message that is sent to a specific work queue within a Coventry Application called WCMS
  • 73. Workers’ Comp – Message Center… Coventry Health Care – For Public Use Both Workers’ Comp and other affiliated Plan messages will appear together in the Inbox
  • 74.  Copies of Health Plan & PPO Fee Schedule submitted inquiries are placed in ‘Sent’ folder, while immediate notifications and responses from the Health Plan reside in ‘Inbox’  For Workers’ Comp inquiries ALL messages remain in ‘Inbox’, NOTHING gets placed into ‘Sent’ tab/folder; Initial Notification remains as ONLY item and reference to submitted request/sent inquiry — ALL follow up notes/comments are placed into ‘Message’ section of request for DP user to review until ‘Status’ is listed as Final and ‘Resolution Date’ is provided/displayed. Workers’ Comp – Message Center… Coventry Health Care – For Public Use
  • 75. Coventry Health Care – For Public Use Workers’ Comp – Message Center… Example of Sent Message with several updates
  • 76. Workers’ Comp – Jopari Portal… Coventry Health Care – For Public Use
  • 77. Workers’ Comp – Jopari Portal… Coventry Health Care – For Public Use
  • 78. Workers’ Comp – Refer a Patient… Coventry Health Care – For Public Use
  • 79. Workers’ Comp – Refer a Patient… Coventry Health Care – For Public Use
  • 80. Workers’ Comp – Provider Resources… Coventry Health Care – For Public Use The Important Links will redirect the users to pages within the Workers’ Comp website; Additional Documents will open in Adobe PDF
  • 81. Coventry Health Care – For Public Use Workers’ Comp – Provider Resources… Follow the instructions on the page to display a State Mandated Fee Schedule
  • 82. Workers’ Comp – Provider Resources… Coventry Health Care – For Public Use To nominate a provider complete the required fields on the Nomination Request and click the Submit button to receive more information
  • 83. Thank you for your time… For Technical Assistance, please contact Net Support at 866-629-3975 Coventry Health Care – For Public Use