January 1, 2015
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ADMINISTRATION

CLAIMS

MEDICAL POLICY

ADMINISTRATION

Checking Member EligibilityCheckingMemberEligibility

During this time of transition, it's important to check each patient's eligibility using one of these options:
 
Use our secure Provider website to find answers all day, every day - no waiting.

  1. Log on 24/7 and enter the ID number, or find an ID number using the patient's name and birth date.
     
  2. Contact us for help.
    • Follow prompts when you dial 1.888.324.2064, available 24/7. You'll need to enter the patient's ID number and birth date.
    • Use our Contact Us tool to direct your question to the correct area. The Contact Us tool includes phone numbers, website resources, and an online form that requests information we need to research your question.
    • Call Member Services at 1.888.324.2064 between 7 a.m. and 6 p.m., Monday through Friday.
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Continue Your Billing Service's Secure Access to Your AccountsBillingServiceSecureAccess
Annual verification response required to avoid disruption

If you granted a billing service access to our secure Provider website to manage your administrative functions in 2014, you'll receive an annual verification in 2015. We send a verification request one year from the date the billing service received access on your behalf.
 

We also contact you for verification before granting access to a third-party. 
 

Please respond promptly when you receive either request. This helps us safeguard your patient's protected health information (PHI) and provides an appropriate billing service with prompt or continued access to your accounts.
  

If your relationship with a billing service terminates, please call 1.855.699.6694 to revoke access.

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Find Past Topics Quickly Using New Provider Alert Subject IndexProviderAlertSubjectIndex

Find previously published items quickly  
 

Use the new  Provider Alert Subject Index to locate previously covered topics. Our subject index is available from the Archives page and the main portion of the News page. The index includes links to the identified issues. 
 

We've also changed our News page to make it easier to find topics of interest.

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CLAIMS

File 2014 ServicesFile2014Services

We encourage you to file claims for 2014 services no later than March 1, 2015. For inpatient hospital claims that will span from 2014 to 2015, please submit an interim claim. 
 

Multiple interim claims may be billed throughout the hospital stay followed by the final claim with the appropriate discharge status. Inpatient interim claims contain a unique Type of Bill (TOB) and may require a patient status code:


 

Type of Bill
Inpatient DescriptionPatient Status
1121st Claim30 - Still Patient
113Cont. Claim30 - Still Patient
114
Last Claim

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Change in Claim Review TimelinesClaimReviewTimelines

In most cases, a claim can be reviewed for adjustment if requested within one year from the date the claim was processed. Please note the two exceptions, as one has recently changed:

  • Change: Claims that deny to provider liability when a prior authorization was not requested may be appealed up to 180 days from the date of the claim's denial.
  • Claims that deny because they are received after the timely filing requirement may be appealed up to 60 days from the date of the claim's denial.

To request a claims appeal or adjustment, select the appropriate claims form.

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MEDICAL POLICY

Updated and New Medical Policy Information PostedMedicalPolicyInformation

To see more information about the following medical policy updates and additions, check the Medical Policy Update dated January 2015:
 

Medical Services


Pharmacy Services

Always check the most current information using our Medical Policies/Coverage Criteria.

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PHARMACY

Drug List Changes for First Quarter 2015 AvailableDrugListChanges

To see a list of recent and upcoming changes to the 2015 CoOportunity Health Drug List, use these resources:

Always check the most current information using the Drug List.

Hepatitis Drug Prior Authorization Form Includes a Member PageHepatitsDrugPriorAuth
To help our members take a more active role in their health, we've recently updated our Forms page to include a Hepatitis Medication Regimen Initial Request Form. Please complete this form to request a prior authorization when prescribing Harvoni�, Sovaldi�, or Olysio�.

This form outlines items you should discuss with our member to help them understand their responsibility for the drug therapy's success, and the approximate cost of these drugs - around $1000 per day. Please ask our members to sign the second page of the form at the conclusion of your discussion.
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