BENEFITS & ELIGIBILITY
- UNDERSTANDING DEDUCTIBLES, OUT OF POCKET MAXIMUM AND COINSURANCE
- BILLING / INSURANCE RULES
- MEDI-CAL PRODUCTS / SOC / CCS WCM
- WHAT TO DO WHEN WE'RE NOT CONTRACTED WITH INSURANCE
- SUTTER INSURANCE
- AETNA
- BLUE SHIELD / BLUE CARD OF CALIFORNIA
- ANTHEM BLUE CROSS
- UNITED HEALTHCARE
- TRICARE
- WESTERN HEALTH
- LIST OF INSURANCE THAT REQUIRE AUTH
- ALLOWED AMOUNT EXCEL SHEET
- CPT Codes
1 . Understanding Copay, Deductible, Coinsurance and Out of pocket maximum
Copayment: is a set rate you pay for prescriptions, doctors visits and other types of care.
Deductible: In an insurance policy the deductible is the amount paid out of pocket by the policyholder before an insurance provider will pay an expenses. How it works: If your plan's deductible is $1500, you'll pay 100% of eligible health care expenses until the bills total $1500 (this can vary based on the insurances schedule of benefits) . After that, you share the cost with your plan by paying coinsurance.
Coinsurance: Coinsurance is the percentage of costs you pay after you've met your deductible. Coinsurance depends on your insurance plan. Out of Pocket maximum: What you pay towards your plan's deductible, coinsurance and copays are all applied to your out-of pocket max. Once you reach your out-of-pocket max, your plan pays 100% of the allowed amount for covered services
We look at both individual deductible and family deductible. Whichever is lower is the deductible
| Coinsurance vs. Copays: A Comparison | |
|---|---|
| Coinsurance | Copays |
| varies as a percentage of the cost of visit or procedure | fixed-dollar amount per visit or procedure |
| same percentage applies to all procedures | may vary depending on type of visit or procedure |
| kicks in after deductible has been met | often paid before deductible has been reached |
We look at both individual deductible and family deductible. Whichever is lower is the deductible we collect. If our services are greater than the deductible, we collect the deductible. If the deductible is greater than our services, we would collect for our services which would go towards their deductible. If their deductible is met but they still have an out of pocket you will collect their co pay and if they have a coinsurance you will collect both until their out of pocket maximum (OOP) has been met. Once the OOP is met the insurance will cover them at 100%
2 . BILLING/ INSURANCE RULES
PPO: Preferred Provider Organization. PPO plans gives members access to a local network of doctors and hospitals. They also have the flexibility to see any other provider anywhere in America. That's as long as the doctor particpates and accepts the member's health plan. A PPO health insurance plan provides more choices when it comes to your healthcare, but there will also be a higher out-of-pocket costs associated with these plans.
HMO: Health Maintenance Organization. Members of HMO plans must go to network providers to get medical care and services. That doesn't mean they can't ever see a doctors who's outside of HMO network, but unless it's an emergency, the member may have to pay the whole cost for their medical care. HMOs are typically cheaper than PPOs but they tend to have smaller networks, People with HMO are assigned to a provider in network EPO: Exclusive Provider Organization. EPO is a type of health plan that offers a local network of doctors and hospitals for you to choose from. An EPO is usually more pocket friendly than a PPO plan. However if you choose to get care outside of your plan's network, it usually will not be covered except in an emergency
3 . Verifying Medi-Cal
https://www.medi-cal.ca.gov/Eligibility/Eligibility.aspx
When verifying Medi-Cal, you want to click single subscriber. Then you will fill out all the spaces. Medi-Cal numbers will always start with the number 9, it will be 9 digits long and end in a letter. For example, 97234072H. Under Issue Date and Service date you will put today's date.
If a patient has straight Medi-Cal the Eligibility message will be completely green. Save the eligibility into the patient's folder and include the month date / year. EX. Mcal Elig 03.23
Straight Med-Cal does not require authorization (NAR).
If a patient doesn't have straight Medi-Cal the Eligibility message will be yellow. Always read the Eligibility message. After Health Plan Member: it will tell you what other insurance this pt has. Here's another example:
Always adjust the coverage on Epic if the insurance does not match the coverage you verify.
Share of Cost (SOC)
REVIEW CAREFULLY AS THE ABOVE EXAMPLE IS COVERED IN FULL FOR PREGNANCY CARE.
Some medi-cal subscribers are required to pay or agree to pay a monthly dollar amount towards their medical expenses before they qualify for their for Medi-cal benefits. SOC is determined by the county welfare department and is based on the income a subscriber receives. Providers may collect payments the day of service or allow a subscriber to pay for these services through a payment plan.
How to clear a share of cost is in the link provided above
CCS
https://cmsprovider.cahwnet.gov/PEDI/clientSearch.action
CCS is a State program for children with certain diseases or health problems. Through this program, children up to 21 years old can get the health care and services they need.
When verifying Medi-Cal sometimes you will see CCS Eligible. Always verify if the pt has CCS on the website by entering the Medi-Cal # in Client Index Number or by Last name, first name and DOB.
Here is an example of a CCS SAR:
The SAR should have our physician's name or "Cardiac Center". If the pt's Sar is expired, has an active CCS account but no sar with our facility / doctors or if the pt does not have CCS at all, you will need to request a new SAR.
Here is a blank NEW SAR request as well as an Existing client SAR request:
(When requesting a SAR for an existing client find the patient in the CCS Site first to reference existing details.)
Once you complete the request you will need to fax the request to the patient's county. You can find their county on CCS if they're already established, or you can find their county in EPIC under Demographics.
A patient has to be CCS Eligible in order to get an approved SAR. For a list of CCS-eligible conditions you can go to the website https://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx
When creating your superbill, under NOTES/ AUTH you will put the CCS SAR number, 01 if it's a physician, 02 if it's a facility and the expiration date. For example, it will look like this
97068426460-01/MANOHAR EXP 06/03/2023 or
97068426460-02/CARDIAC CENTER EXP 06/03/2023
PARTNERSHIP
https://provider.partnershiphp.org/UI/Login.aspx
Verifying Partnership is fairly easy. First verify Eligibility on Medi-cal and then the partnership website. Click the link above, create an account or log in. Once that step is done and you have access to the portal you will come across this screen
To verify they are active with partnership click " Eligibility Modules". From there you will receive a couple options. Click "eEligibility"
You will the be directed to another page
Here you can put the Cin number (Client index number. In other words it's the member ID. The medi-cal ID # and PHP CIN are the same) you also have the option to verify using the Social of the patient or you can verify using last name, first name and DOB. Search member and then select their account.
Eligibility page will give you patient's demographics, Eligibility details such as the County, if they're CCS eligible, american indian, other insurance, SOC, and primary language. NAR for CCS eligible patients (for certain counties only which I will go over in the next chapter) nar for American indian , for a Direct or special member. To see if a patient is a Direct member it's on the eEligibility page in the right corner of the screen.
Under PCP Messages if there's a notification it'll state they are a direct member and no RAF is required. If the patient is not CCS eligible, American indian or a Direct member a Raf is required. To obtain a RAF (authorization) you can find it on google or in the billing folder under "Rqst forms"
You can find all the information you need to complete this form on the partnership website in eEligibility. There you can just copy PCP, fax, name, cin and dob and paste it into the fields. If you're unsure of the Diagnosis code google is your friend. Utilize it to look up the diagnosis code. Type in the diagnosis and ICD. For example type in Cardiac murmur ICD 10. Google will tell you the diagnosis code is R01.1. Under Comments if it's a follow up I typically write "Patient is 3 year old female to be seen due to ASD/PFO. Raf required to evaluate and treat. Thank you" I then fax to the pcp with the last most previous medical note.
To see if there's a raf already or if your request is pending/ approved go back to main screen and find "Authorizations (RAFs and TARs) Once you get into there, the screen will look like this
Go into "eRAF Status Checking" and enter the member ID once directed to.
At the bottom it will tell the RAF number, status , exp date and pcp. Pcp has to be current. If they're no longer with this pcp you have to request a new RAF with current pcp.
PARTNERSHIP AND CCS (WCM)
Partnership and CCS have a program called Whole Child Model (WCM). Partnership members who have been receiving CCS care through their county will get these services through Partnership Whole Child Model program. PHC helps these families with CCS care and Medi-Cal covered services.
Patients who are eligible have to be under 21 years of age, they have to be active with partnership and be CCS eligible. ( https://www.dhcs.ca.gov/services/ccs/Pages/medicaleligibility.aspx)
Under this model, patients get CCS care from Partnership instead of their county CCS Program. This helps patients get all of their care through one system and prevents confusion about where they get care. Patients get all covered services from partnership meaning they get primary and specialty services, hospital visits, some mental health services.
Claims are to go to partnership since they are coordinating services
Health Net Eligibility
When verifying a patient has Health Net simply click Eligibility and fill out open space. If the patient is Eligible it will state in green. Notice under PPG information it says Prime Community Care of Central Valley. Often times patients don't just have Health Net. Sometimes they also have Prime, River city, Sequoia, Nivano, Riverbank and more. Riverbank does not require authorization, but others do. If you're ever unsure if an authorization is needed, you can always call the insurance and ask or skip to section 11. Don't forget to save the Eligibility to the p drive.
Prime Community Health Care Authorization
When you want to check the status of an authorization or see if a patient has an authorization in place already, in the far-left section you'll click Authorization/ Referral. Once it drops down, you'll click view / search Authorization and fill out member ID.
If a patient has an authorization always check if:
- We used it already.
- The expiration date to ensure it's still valid.
- It has all the cpt codes required. Keep in mind Fetal cpt codes are different.
If no auth was created, click Auth/ Referral submission.
Include member ID and press enter. Everything else will generate. Edit Priority in the far top right if needed. Under requesting provider, referring provider and facility provider include NPI for our facility or Dr. For diagnosis add Dx code and under service requested add codes 93303, 93306, 93000, 93320, 93325, 99245 (if it's a new pt), 99215, 93225, 93227, 93270 and 93272. For Qty put 2 under Follow up (99215) and Echos/ EKG (93303, 93306, 93320, 93325, 93000). For a Fetal CPT Codes are 99245, 99215, 76825, 76826, 76827, 93000. Please fill out Clinical Indication for request.
Here are some Examples:
- PATIENT COMING IN FOR AN INITIAL CONSULTATION DUE TO CARDIAC MURMUR DISCOVERED. ECHO/EKG TO BE DONE IN OFFICE. SEE REFERRAL ATTACHED THANK YOU
- PT COMING IN FOR A FOLLOW UP CONSULT DUE TO PALPITATIONS. HOLTER CODES WILL BE REQUIRED. PLEASE SEE SUPPORTING DOCUMENTS ATTACHED, THANK YOU.
Next to Basic Details, upload documents. It can be last office visit note or referral. Then Save to the P drive.
River City Authorization
https://eznet.rcmg.com/EZ-NET60/Webportal/EZNET/AuthorizationReferralSearch.aspx
When checking for RC auth click Auth/ Referrals and at the drop down click inquiry. Fill in the member ID and search. If an auth was created it will populate. Please check if auth was approved, if we used it already and if all the necessary codes were included. Keep in mind fetal CPT codes are different.
If you need to create an authorization press auth submission instead of inquiry and fill in the blank spaces.
Seqouia
https://www.capcms.com/capconnect/loginv2.aspx
Health plan of San Joaquin
https://provider.hpsj.com/dre/default.aspx?SessionExpired=YES
a. Example: This patient is coming in for a full initial consultation due to a new diagnosis that was found. We will need to see her for a Consult, Ekg and Echo to evaluate patient.
- Submit Auth Req
- Do you have supporting Documents: Yes
- Browse Electronic Document
- Continue
- View Confirmation and PDF Summary
- #R0000000000 Select document and save it in the patient's chart.
When creating the super bill, if the pt already has an approved Auth
Put the insurance, the auth number and the expiration date under NOTES/ AUTH
Example:
HPSJ R002265465401 EXP 06-18-2023
4 .What to do if a patient has an insurance we are not contracted with
When dealing with an insurance you're unfamiliar with or smaller private insurance, I always ask if we're in network. I give them both facility NPI and the servicing provider NPI. If we're not in Network with either I call the pt to let know we're not in network with their insurance. If they still want to be seen by us, the out of pocket cost is 500 dollars. If not I recommend they call thier pcp and ask to be referred to cardiologist in network.
There's very few insurance's we're not contracted with. Allcare being one of them. Allcare is an hmo group. If an insurance (typically blueshield or Bluecross) reflects Allcare as the group, call the patient, let them know we're not grouped with their hmo and the self pay cost or be referred to a cardio in net.
5 . Sutter Insurance
When looking at Sutter products:
if the Sutter Member ID starts with Y it will either be Sutterselect EPO Plus, or it will be Sutter UMR. If the Member ID starts with M it will always be Sutter Health Plus.
The Sutterselect eligibility looks like this:
When verifying Insurance ALWAYS check if the insurance is active. Look at the Subscriber name, DOB and make sure it matches on epic. If Epic does not match what the insurance is showing, update/ correct what is in Epic. If you can, also add the group number, group name and effective date in Epic. The idea is to fill out as much information possible.
Going back to the Eligibility you can see under Medical benefits the pt has a deductible of 250. which is less than our service. So, in this case we will collect that 250, plus the copayment (20) and the coinsurance (10%) since we are collecting the whole deductible.
To find the coinsurance we need to
- add our services 365 (Echo) + 18 (EKG) = 383
- subtract our services from their deductible. 383-250= 133
- apply the coinsurance percentage. So 133 x 10%= 13
Once we get our coinsurance, we add everything together.
Ex. 250+20+13=283. That is the patient's out of pocket for this upcoming appointment. Always call to inform pt's of their OOP.
Here is an example on what to say:
"Hi there this is *name * calling from Capital Pediatric Cardiology to let you know your out of pocket expense for this upcoming appt. At the time of service, we will be collecting 283 dollars. This is due to your deductible of 250 dollars, your co pay of 20 dollars and your coinsurance of 10%. Do you have any questions for me?"
Always remember to save the eligibility in the patient's chart.
Sutter Select and Sutter UMR do not require authorization. However, if the patient has Sutter Health plus, the patient may need authorization.
When verifying Sutter Health Plus (SHP) be sure to check the Medical group name. If the medical group name says Sutter Medical Group (SMG) no auth is required but if it shows Sutter Gould Medical Foundation (SGMF) then Authorization is needed.
To obtain auth you can call PCP or you can fax over a request. Calling might help you obtain it a little faster.
For SHP the subscriber ID will always end in -01. Please update on Epic if it shows otherwise. When calculating the cost at the time of service be sure to check the Benefits and Coverage Matrix right above the medical group name.
This is the patients schedule of benefits. This will help you determine the cost for the visit. Next to Diagnostic testing it shows 30 dollar copay per procedure. Every plan is different.
6 . AETNA
To verify Aetna, you have to go to Availity.
Under payer, the drop down will show 2 different Aetna's. Pick Aetna (Commercial & Medicare)
Here is an example of an active Aetna plan. Note everything highlighted. If the subscriber in Epic does not match the subscriber on the insurance you must update Epic. Also be sure to add the eligibility date under "Policy" in Epic. I also highlighted HSA. HSA stands for health Savings Account. Health savings account is a type of personal savings account you can set up to pay certain health care costs. An HSA allows you to put money away and withdraw it tax free, as long as you use it for qualified medical expenses. You’re eligible to contribute to an HSA when you’re covered by certain high deductible health plans. Some employers offer HSA and some insurance companies offer HSA.
Above is an example of an inactive plan. I like to look in the patient's folder and see if the insurance on the referral matches the one on Epic. If it doesn't, I like to run the insurance on the referral and then update Epic. If the insurance still shows as inactive, you can reach out to the patient and update the insurance on file.
7 . Blue Shield / Blue Card
https://secure.helpscout.net/docs/63d83b9094c9984f6d3160d2/article/6412239f74cd141bfb9dcb80
When verifying Blue Shield or Blue Cross, always check the caims routing tool on the Blue shield website.
People confuse Blue Shield, Blue Cross and Blue Card often. This is why it is important to check claims routing tool. It tells us who we send the claims to and we verify if it's correct in Epic.
You can search the plan by subscriber ID or by name and dob. Blue Shield often has 3 letters in the beginning of the subscriber ID. If it starts with XEH It is an HMO plan and requires authorization.
To verify the deductible and out of pocket maximum I personally like to use availity. For me it's easier to read however you're more than welcomed to use the Blue shield website. To find the deductible / OOP maximum, click the Deducible drop down.
To find the deductible / OOP maximum on Availity click Anthem - CA as the payer. Fill in all the blank areas and submit.
This plan has a 0 dollar deductible, and a high out of pocket maximum.
When calculating the out of pocket cost, click on "Benefits" in the top right of Blue Shield
Once you click on benefits you'll see "Benefit Categories." You'll want to search in two different areas here. First you can check "Lab and Radiology/Diagnostic Testing" and at the drop down click "Professional Lab/Radiology/Diagnostic Testing" and then click Radiology.
There's no co payment, or coinsurance and their deductible does not apply.
Next place to check is Physician Services. At the drop down press "In Office". If you see Specialist you will check there. If you don't see specialist you can look at Visit/Consultation.
There is a 15 dollar co pay, deductible does not apply but the co pay does apply to annual copay maximum. Keep in mind that because the deductible does not apply, we will just collect the co pay and not collect towards our services. If the deductible did apply we would collect the co pay and collect for our services which would go towards their deductible. (If there is no co pay and it is a new patient we would collect the new patient consult. Please see Fee schedule for new patient consult.) Sometimes we collect 2 co payments. If there's a co pay under Radiology and a copay under Specialist visit, we collect both.
Claims routing tool will also tell you if it's BlueCard. 9 times out of 10 if it's Bluecard, Epic will show the claims address as Anthem Blue Cross. This is incorrect. If claims routing tool shows Blue Shield as the claims mailing address, then change Epic to Blue Shield since that's where the claim will go. You can verify BlueCard on the Blue Shield website as " Other Blue Member" but I recommend verifying BlueCard on Availity.
8 . Anthem Blue Cross
After confirming the payer is Anthem on Blue Shield's claims routing tool you'll open the Availity app, change payer to Anthem-CA, fill in all the blank spaces, under "benefit / service type" search "Professional (physician) visit- Office" and then search for the member. You can search many different ways but Patient ID & DOB is the first patient search option. Once you submit, it will tell you right away if the patient is active or inactive. Add Group number, Group name, Coverage start date and confirm subscriber matches EPIC. Then look at the deductible and out of pocket maximum.
This plan has no deductible, a high out of pocket maximum and a specialist copay of 10 dollars. After verifying the professional office visit go back to the search screen and change the benefit/ service type from physician visit to diagnostic lab and add the cpt code 93303 for Echo.
After you search, scroll down to see if a deductible applies and if there's a coinsurance.
No deductible applies and no coinsurance. After confirming the benefits check to see if an authorization is required. You can do that by logging onto the AIM portal. https://providerportal.com/Default.aspx
Put the service date as today's date an fill out the rest
The only thing you have to pay attention to is Diagnostic Testing. Aim tells you if auth is needed for Diagnostic Testing. In this case it is.
You'll click on Diagnostic testing and change the type from Home to office and then start order request at the bottom left.
For CPT code put 93303 and then add exam. Fetals do not require authorization for AIM. Once you fill out the auth request, save it into the pdrive.
9 . United HealthCare
https://www.uhcprovider.com/?rfid=UHCOContRD
United healthcare is pretty straight forward. You can search by member ID and birthday or by name and DOB
The first thing I like to verify is the subscriber and then I like to go straight to PCP. Sometimes insurances are grouped. Under provider group name it shows Sutter Gould. This means you would need authorization from Sutter gould and not United Health care.
After, you check the patient's deductible and out of pocket maximum, click on "View Additional Services" And then click "Diagnostic lab" and "Diagnostic X-ray"
There's a 0 dollar copay and no coinsurance for Diagnostic lab and X-ray. Now verify Specialist visit.
There's no co insurance but they have a 15 dollar co pay.
To request a United Healthcare authorization
- Click on "Prior Authorization"
- Click " Submission & Status" Under the radiology and cardiology tab.
- Change service type to Cardiology
- Click "Submit Clinical Request"
- Press very top United Healthcare
- Enter any fields with the *
- Submit your request and save it into the pdrive.
10 . Tricare
https://www.tricare-west.com/content/hnfs/home/tw/prov/secure.html
There's two types of Tricare. There's Tricare Prime and there's Tricare select.
Tricare Prime requires authorization. Tri Select, does not. To request a Tricare authorization you can reach out to the patient's Pcp or you can reach out to the patient and let them know authorization is required and have them reach out to their pcp. Authorization takes about two weeks to be approved.
11 . Western Health Advantage
https://www.westernhealth.com/provider/
Western Health Advantage typically starts with "000" and is 11 numbers long. Western Health is always grouped with another insurance. Typically it's Hills Physicians or Mercy (Dignity).
WHA lists the family's Eligibility so be sure you're looking at the correct person.
Under Product information and next to Medical, click on Western health advantage (HMO)
This will tell you your schedule of benefits.
To save Eligibility into the pdrive, Click on " Download/Print" in the top right
12 .List of Insurances that Require Auth
13 . Allowed Amounts
14 . CPT Codes
